Increasing Rates of Bowel Resection Surgery for Stricturing Crohn's Disease in the Biologic Era.

BACKGROUND: The era of biologics is associated with declining rates of surgery for Crohn's disease (CD), but the impact on surgery for stricturing CD is unknown. Our study aimed to assess nationwide trends in bowel resection surgery for obstruction in CD since the introduction of infliximab for CD in 1998. METHODS: Using the Nationwide Inpatient Sample, we performed a nationwide analysis, identifying patients hospitalized for CD who underwent bowel resection for an indication of obstruction between 1998 and 2020 (era of biologics). Longitudinal trends in all CD-related resections and resection for obstruction were evaluated. Multivariable logistic regression identified patient and hospital characteristics associated with bowel resection surgery for obstruction. RESULTS: Hospitalizations for all CD-related resections decreased from 12.0% of all hospitalizations in 1998 to 6.9% in 2020, while hospitalizations for CD-related resection for obstructive indication increased from 1.3% to 2.0%. The proportion of resections for obstructive indication amongst all CD-related bowel resections increased from 10.8% in 1998 to 29.1% in 2020. In the multivariable models stratified by elective admission, the increasing year was associated with risk of resection for obstructive indication regardless of urgency (nonelective model: odds ratio, 1.01; 95% CI, 1.00-1.02; elective model: odds ratio, 1.06; 95% CI, 1.04-1.08). CONCLUSIONS: In the era of biologics, our findings demonstrate a decreasing annual rate of CD-related bowel resections but an increase in resection for obstructive indication. Our findings highlight the effect of medical therapy on surgical rates overall but suggest limited impact of current medical therapy on need of resection for stricturing disease.

In our nationwide analysis, rates of bowel resection for patients with Crohn's disease have declined since the approval of infliximab in 1998. However, rates of resection for obstruction in patients with Crohn's disease continue to increase.

Recent trends and risk factors associated with Clostridioides difficile infections in hospitalized patients with inflammatory bowel disease.

BACKGROUND: Clostridioides difficile infections (CDIs) are common among patients with inflammatory bowel disease (IBD) and can mimic and exacerbate IBD flares, thus warranting appropriate testing during flares. AIMS: To examine recent trends in rates of CDI and associated risk factors in hospitalized IBD patients, which may better inform targeted interventions to mitigate the risk of infection. METHODS: This is a retrospective analysis using the Nationwide Readmissions Database from 2010 to 2020 of hospitalized individuals with Crohn's disease (CD) or ulcerative colitis (UC). Longitudinal changes in rates of CDI were evaluated using International Classification of Diseases codes. Multivariable logistic regression evaluated the association between patient- and hospital-related factors and CDI. RESULTS: There were 2,521,935 individuals with IBD who were hospitalized at least once during the study period. Rates of CDI in IBD-related hospitalizations increased from 2010 to 2015 (CD: 1.64%-3.32%, p < 0.001; UC: 4.15%-5.81%, p < 0.001), followed by a steady decline from 2016 to 2020 (CD: 3.15%-2.27%, p < 0.001; UC: 5.04%-4.27%, p < 0.001). In multivariable models, CDI was associated with the Charlson-Deyo comorbidity index, public insurance, and hospital size. CDI was associated with increased mortality. CONCLUSIONS: Rates of CDI among hospitalized patients with IBD had initially increased, but have declined since 2015. Increased comorbidity, large hospital size, public insurance, and urban teaching hospitals were associated with higher rates of CDI. CDI was associated with increased mortality in hospitalized patients with IBD. Continued vigilance, infection control, and treatment of CDI can help continue the trend of declining infection rates.

Vitamin D for the treatment of inflammatory bowel disease.

BACKGROUND: Vitamin D possesses immunomodulatory properties and has been implicated in the pathogenesis and severity of inflammatory bowel disease (IBD). Animal studies and emerging epidemiological evidence have demonstrated an association between vitamin D deficiency and worse disease activity. However, the role of vitamin D for the treatment of IBD is unclear. OBJECTIVES: To evaluate the benefits and harms of vitamin D supplementation as a treatment for IBD. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was Jun 2023. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in people of all ages with active or inactive IBD comparing any dose of vitamin D with another dose of vitamin D, another intervention, placebo, or no intervention. We defined doses as: vitamin D (all doses), any-treatment-dose vitamin D (greater than 400 IU/day), high-treatment-dose vitamin D (greater than 1000 IU/day), low-treatment-dose vitamin D (400 IU/day to 1000 IU/day), and supplemental-dose vitamin D (less than 400 IU/day). DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. clinical response for people with active disease, 2. clinical relapse for people in remission, 3. quality of life, and 4. withdrawals due to adverse events. Our secondary outcomes were 5. disease activity at end of study, 6. normalisation of vitamin D levels at end of study, and 7. total serious adverse events. We used GRADE to assess certainty of evidence for each outcome. MAIN RESULTS: We included 22 RCTs with 1874 participants. Study duration ranged from four to 52 weeks. Ten studies enroled people with Crohn's disease (CD), five enroled people with ulcerative colitis (UC), and seven enroled people with CD and people with UC. Seventeen studies included adults, three included children, and two included both. Four studies enroled people with active disease, six enroled people in remission, and 12 enroled both. We assessed each study for risk of bias across seven individual domains. Five studies were at low risk of bias across all seven domains. Ten studies were at unclear risk of bias in at least one domain but with no areas of high risk of bias. Seven studies were at high risk of bias for blinding of participants and assessors. Vitamin D (all doses) versus placebo or no treatment Thirteen studies compared vitamin D against placebo or no treatment. We could not draw any conclusions on clinical response for UC as the certainty of the evidence was very low (risk ratio (RR) 4.00, 95% confidence interval (CI) 1.51 to 10.57; 1 study, 60 participants). There were no data on CD. There may be fewer clinical relapses for IBD when using vitamin D compared to placebo or no treatment (RR 0.57, 95% CI 0.34 to 0.96; 3 studies, 310 participants). The certainty of the evidence was low. We could not draw any conclusions on quality of life for IBD (standardised mean difference (SMD) -0.13, 95% CI -3.10 to 2.83 (the SMD value indicates a negligent decrease in quality of life, and the corresponding CIs indicate that the effect can range from a large decrease to a large increase in quality of life); 2 studies, 243 participants) or withdrawals due to adverse events for IBD (RR 1.97, 95% CI 0.18 to 21.27; 12 studies, 1251 participants; note 11 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 12). The certainty of the evidence was very low. High-treatment-dose vitamin D versus low-treatment-dose vitamin D Five studies compared high treatment vitamin D doses against low treatment vitamin D doses. There were no data on clinical response. There may be no difference in clinical relapse for CD (RR 0.48, 95% CI 0.23 to 1.01; 1 study, 34 participants). The certainty of the evidence was low. We could not draw any conclusions on withdrawals due to adverse events for IBD as the certainty of the evidence was very low (RR 0.89, 95% CI 0.06 to 13.08; 3 studies, 104 participants; note 2 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 3). The data on quality of life and disease activity could not be meta-analysed, were of very low certainty, and no conclusions could be drawn. Any-treatment-dose vitamin D versus supplemental-dose vitamin D Four studies compared treatment doses of vitamin D against supplemental doses. There were no data on clinical response and relapse. There were no data on quality of life that could be meta-analysed. We could not draw any conclusions on withdrawals due to adverse events for IBD as the certainty of the evidence was very low (RR 3.09, 95% CI 0.13 to 73.17; 4 studies, 233 participants; note 3 studies reported withdrawals but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 1 study rather than 4). AUTHORS' CONCLUSIONS: There may be fewer clinical relapses when comparing vitamin D with placebo, but we cannot draw any conclusions on differences in clinical response, quality of life, or withdrawals, due to very low-certainty evidence. When comparing high and low doses of vitamin D, there were no data for clinical response, but there may be no difference in relapse for CD. We cannot draw conclusions on the other outcomes due to very low certainty evidence. Finally, comparing vitamin D (all doses) to supplemental-dose vitamin D, there were no data on clinical relapse or response, and we could not draw conclusions on other outcomes due to very low certainty evidence or missing data. It is difficult to make any clear recommendations for future research on the basis of the findings of this review. Future studies must be clear on the baseline populations, the purpose of vitamin D treatment, and, therefore, study an appropriate dosing strategy. Stakeholders in the field may wish to reach consensus on such issues prior to new studies.

Use of oral diet and nutrition support in management of stricturing and fistulizing Crohn's disease.

Crohn's disease (CD), a form of inflammatory bowel disease, involves chronic inflammation within the gastrointestinal tract. Intestinal strictures and fistulas are common complications of CD with varying severity in their presentations. Modifications in oral diet or use of exclusive enteral nutrition (EEN) are common approaches to manage both stricturing and fistulizing disease, although supporting research evidence is generally limited. In the preoperative period, there is strong evidence that EEN can reduce surgical complications. Parenteral nutrition (PN) is often utilized in the management of enterocutaneous fistulas, given that oral diet and EEN may potentially increase output in proximal fistulas. This narrative review highlights the current practices and evidence for the roles of oral diet, EEN, and PN in treatment and management of stricturing and fistulizing CD.

Trends in the Prevalence of Hepatitis C Infection During Pregnancy and Maternal-Infant Outcomes in the US, 1998 to 2018.

Importance: Injection drug use is the primary risk factor for hepatitis C virus (HCV) infection in adults. More than one-third of newly reported HCV cases occur in women, particularly among persons aged 20 to 39 years. However, nationally representative data on HCV during pregnancy are limited. Objective: To estimate the temporal trend of HCV-positive pregnancies during the opioid epidemic and identify HCV-associated maternal and perinatal outcomes. Design, Setting, and Participants: A cross-sectional study was performed with data from the US, from calendar year 1998 through 2018. Data analysis was conducted from November 14, 2021, to May 14, 2023. Participants included women during in-hospital childbirth or spontaneous abortion in the National Inpatient Sample of the Healthcare Cost and Utilization Project. Exposure: Maternal HCV infection. Main Outcomes and Measures: The main outcome was the temporal trend, measured as change in the annual prevalence, in the prevalence of HCV positivity among pregnant women since the start of the opioid epidemic in the late 1990s. Secondary outcomes were the associations shown as relative odds between maternal HCV infection and maternal and perinatal adverse events. Results: During the study period, more than 70 million hospital admissions resulted in childbirth or spontaneous abortion. Among them, 137 259 (0.20%; 95% CI, 0.19%-0.21%) involved mothers with HCV; these individuals were more often White (77.4%; 95% CI, 76.1%-78.6%), low-income (40.0%; 95% CI, 38.6%-41.5%), and likely to have histories of tobacco (41.7%; 95% CI, 40.6%-42.9%), alcohol (1.8%; 95% CI, 1.6%-2.0%), and opioid (28.9%; 95% CI, 27.3%-30.6%) use compared with HCV-negative mothers. The median age of women with HCV was 28.0 (IQR, 24.3-32.2) years, and the median age of HCV-negative women was 27.2 (IQR, 22.7-31.8) years. The prevalence of HCV-positive pregnancies increased 16-fold during the study period, reaching 5.3 (95% CI, 4.9-5.7) cases per 1000 pregnancies in 2018. Age-specific prevalence increases ranged from 3-fold (age, 41-50 years) to 31-fold (age, 21-30 years). Higher odds of cesarean delivery, preterm labor, poor fetal growth, or fetal distress were associated with HCV-positivity during pregnancy. However, no significant differences were observed in gestational diabetes, preeclampsia, eclampsia, or stillbirths. Conclusions and Relevance: In this cross-sectional study, the prevalence of HCV-positive pregnancies increased markedly, and maternal HCV infection was associated with increased risks for adverse perinatal outcomes. These data may support recent recommendations for universal HCV screening with each pregnancy.

ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures.

A biliary stricture is an abnormal narrowing in the ductal drainage system of the liver that can result in clinically and physiologically relevant obstruction to the flow of bile. The most common and ominous etiology is malignancy, underscoring the importance of a high index of suspicion in the evaluation of this condition. The goals of care in patients with a biliary stricture are confirming or excluding malignancy (diagnosis) and reestablishing flow of bile to the duodenum (drainage); the approach to diagnosis and drainage varies according to anatomic location (extrahepatic vs perihilar). For extrahepatic strictures, endoscopic ultrasound-guided tissue acquisition is highly accurate and has become the diagnostic mainstay. In contrast, the diagnosis of perihilar strictures remains a challenge. Similarly, the drainage of extrahepatic strictures tends to be more straightforward and safer and less controversial than that of perihilar strictures. Recent evidence has provided some clarity in multiple important areas pertaining to biliary strictures, whereas several remaining controversies require additional research. The goal of this guideline is to provide practicing clinicians with the most evidence-based guidance on the approach to patients with extrahepatic and perihilar strictures, focusing on diagnosis and drainage.

Impact of malnutrition and nutrition support in hospitalised patients with inflammatory bowel disease.

BACKGROUND: Malnutrition is prevalent in patients with inflammatory bowel disease (IBD) and has been associated with worse clinical outcomes. AIMS: This observational study examines trends in protein-calorie malnutrition (PCM) amongst hospitalised IBD and non-IBD patients, and the association between (1) malnutrition and (2) nutrition support and hospitalisation outcomes. METHODS: We queried the Nationwide Readmissions Database from 2010 to 2018 for hospitalisations with and without IBD. Amongst patients with IBD and concurrent PCM, we identified those who received nutrition support. Multivariable Cox proportional hazards and Kaplan-Meier analyses evaluated the associations between PCM and nutrition support and readmission and mortality. Multiple linear regression described the association between compared variables and length of stay (LOS) and total hospitalisation costs. RESULTS: This study included 1,216,033 patients (1,820,023 hospitalisations) with Crohn's disease (CD), 832,931 patients (1,089,853 hospitalizations) with ulcerative colitis (UC) and 240,488,656 patients (321,220,427 hospitalisations) without IBD. Admitted IBD patients were 2.9-3.1 times more likely to have PCM than non-IBD patients. IBD patients with PCM had a higher risk of readmission and mortality, as well as longer LOS and higher hospitalisation costs. Nutrition support (parenteral and enteral) was associated with a reduced risk of readmission, but higher mortality increased LOS and higher total hospitalisation costs. CONCLUSIONS: Malnutrition in hospitalised IBD patients remains an important contributor to readmission, mortality, LOS and healthcare costs. Providing nutrition support to IBD patients may reduce the risk of readmission. Further studies are needed to evaluate the role of nutrition support amongst hospitalised IBD patients to optimise disease and healthcare outcomes.

American College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac Disease.

This guideline presents an update to the 2013 American College of Gastroenterology Guideline on the Diagnosis and Management of Celiac Disease with updated recommendations for the evaluation and management of patients with celiac disease (CD). CD is defined as a permanent immune-mediated response to gluten present in wheat, barley, and rye. CD has a wide spectrum of clinical manifestations that resemble a multisystemic disorder rather than an isolated intestinal disease, and is characterized by small bowel injury and the presence of specific antibodies. Detection of CD-specific antibodies (e.g., tissue transglutaminase) in the serum is very helpful for the initial screening of patients with suspicion of CD. Intestinal biopsy is required in most patients to confirm the diagnosis. A nonbiopsy strategy for the diagnosis of CD in selected children is suggested and discussed in detail. Current treatment for CD requires strict adherence to a gluten-free diet (GFD) and lifelong medical follow-up. Most patients have excellent clinical response to a GFD. Nonresponsive CD is defined by persistent or recurrent symptoms despite being on a GFD. These patients require a systematic workup to rule out specific conditions that may cause persistent or recurrent symptoms, especially unintentional gluten contamination. Refractory CD is a rare cause of nonresponsive CD often associated with poor prognosis.

Dietary Interventions for the Treatment of Inflammatory Bowel Diseases: An Updated Systematic Review and Meta-analysis.

BACKGROUND & AIMS: This study aimed (1) to systematically review controlled trials of solid food diets for the treatment of inflammatory bowel disease (IBD); and (2) to grade the overall quality of evidence. METHODS: Systematic review of prospective controlled trials of solid food diets for the induction or maintenance of remission in IBD. Two authors independently performed study selection, data extraction, and assessment of certainty of evidence. Meta-analyses were performed on studies with quantitative data on response, remission, and relapse. RESULTS: There were 27 studies for meta-analysis. For induction of remission in Crohn's disease (CD), low refined carbohydrate diet and symptoms-guided diet outperformed controls, but studies had serious imprecision and very low certainty of evidence. The Mediterranean diet was similar to the Specific Carbohydrate Diet (low certainty of evidence), and partial enteral nutrition (PEN) was similar to exclusive enteral nutrition (very low certainty of evidence). PEN reduced risk of relapse (very low certainty of evidence), whereas reduction of red meat or refined carbohydrates did not (low certainty of evidence). For ulcerative colitis, diets were similar to controls (very low and low certainty of evidence). CONCLUSIONS: Among the most robust dietary trials in IBD currently available, certainty of evidence remains very low or low. Nonetheless, emerging data suggest potential benefit with PEN for induction and maintenance of remission in CD. Reduction of red meat and refined carbohydrates might not reduce risk of CD relapse. As more dietary studies become available, the certainty of evidence could improve, thus allowing for more meaningful recommendations for patients.

Dietary Patterns and Their Association With Symptoms Activity in Inflammatory Bowel Diseases.

BACKGROUND: Existing studies on diet and inflammatory bowel disease (IBD) have largely focused on evaluating the effects of single nutrients or whole predesigned diets but not on evaluating the effects of diverse dietary patterns. This study applied unsupervised methods to identify dietary patterns of individuals with IBD and evaluated their association with symptoms activity. METHODS: This retrospective study of adults with IBD collected current clinical data and typical diet recalled from the time when in clinical remission. Discrete dietary structures were defined by k-means clustering. Multivariable logistic regression evaluated the relationship between diet clusters and the presence of active symptoms, while adjusting for age, sex, disease duration, disease behavior, and medication use. RESULTS: Of 691 participants, 36% had Crohn's disease (CD) and 64% had ulcerative colitis (UC) or IBD-unclassified. Five major dietary clusters were identified: 2 resembled a Western diet (WD) (WD1, WD2), 1 resembled a balanced diet, and 2 resembled a plant-based diet (PB) (PB1, PB2). Compared with WD1, PB2 was associated with lower odds of active symptoms for CD (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.12-0.83) and UC (OR, 0.31; 95% CI, 0.15-0.62). PB1 was associated with lower odds of active symptoms for participants with UC (OR, 0.45; 95% CI, 0.23-0.90) but not for participants with CD (OR, 0.95; 95% CI, 0.36-2.51). CONCLUSIONS: Diets with increased intake of fruits and vegetables, reduction of processed meats and refined carbohydrates, and preference of water for hydration were associated with lower risk of active symptoms with IBD, although increased intake of fruits and vegetables alone did not reduce risk of symptoms with CD.

The study used machine learning methods to provide minimally biased classifications of dietary patterns among individuals with inflammatory bowel diseases, followed by an evaluation of the association between the different diet clusters and symptoms activity.

What's New in the Postoperative Management of Crohn's Disease?

Patients with Crohn's disease (CD) often require surgical resection due to complications, such as strictures and abscesses, or disease refractory to medical therapy. To understand the evolving management of patients with CD after surgery, we outline the risk factors for postoperative recurrence, advances in postoperative endoscopic evaluation and characterization of recurrence, noninvasive methods of assessing postoperative recurrence, use of postoperative prophylactic medical therapy including newer biologics, and novel surgical methods to reduce postoperative recurrence. The Rutgeerts score (RS) was developed to predict progression of disease based on endoscopic appearance postoperatively and to guide medical therapy. However, this scoring system groups ileal and anastomotic lesions into the same category. A modified RS was developed to separate lesions isolated to the anastomosis and those in the neo-terminal ileum to further understand the role of anastomotic lesions in CD progression. Additional scoring systems have also been evaluated to better understand these differences. In addition, noninvasive diagnostic methods, such as small bowel ultrasound, have high sensitivity and specificity for the detection of postoperative recurrence and are being evaluated as independent methods of assessment. Studies have also shown a reduction in endoscopic recurrence with postoperative anti-TNFα therapy. However, preoperative exposure to anti-TNFα therapy may impact postoperative response to these medications, and therefore, determining optimal postoperative prophylaxis strategy for biologic-experienced patients requires further exploration. Lastly, new surgical modalities to reduce postoperative recurrence are currently being investigated with preliminary data suggesting that an antimesenteric functional end-to-end anastomosis (Kono-S) may decrease postoperative recurrence.

Thiopurine Monotherapy Is Effective in Maintenance of Mild-Moderate Inflammatory Bowel Disease.

BACKGROUND: Crohn's disease (CD) and ulcerative colitis (UC) are complex, inflammatory bowel diseases (IBD) with debilitating complications. While severe IBD typically requires biologic agents, the optimal therapy for mild-moderate IBD is less clear. AIMS: To assess the efficacy of thiopurine monotherapy for maintenance of mild-moderate IBD and clinical variables associated with treatment outcome. METHODS: This retrospective study included adults with mild-moderate IBD who were started on thiopurines without biologic therapy. The primary outcome was therapy failure, defined by disease progression based on clinical, endoscopic, and radiologic criteria. Clinical variables were extracted at time of thiopurine initiation. Univariable and multivariable Cox proportional hazards models were used to examine the independent contribution of the clinical variables on treatment response. RESULTS: From 230 CD patients, 64 (72%) were free of treatment failure with mean follow-up of 3.3 years. In our multivariable model, thiopurine failure was associated with concomitant systemic steroid administration (aHR 2.43, p = 0.001), whereas protective factors included concomitant oral 5-aminosalicylic acid (5-ASA) therapy (aHR 0.54, p = 0.02) and non-fistulizing, non-stricturing disease (aHR 0.57, p = 0.047). From 173 UC patients, 50 (71%) were free from treatment failure with mean follow-up of 3.3 years. On multivariable analysis, concomitant oral steroids were associated with thiopurine failure (aHR 2.71, p = 0.001). Only 13 (4%) discontinued thiopurines from adverse effects. CONCLUSIONS: In mild-moderate uncomplicated IBD, thiopurine monotherapy was associated with longitudinal maintenance of remission and may represent a lower-cost, convenient, and effective alternative to biologics. Multiple clinical variables were predictive of treatment response.

The Impact of NAFLD on Hospitalization Outcomes in Patients With Inflammatory Bowel Diseases: Nationwide Analysis.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is highly prevalent in patients with inflammatory bowel diseases (IBD). Yet, the impact of NAFLD on outcomes, along with the contribution of nonmetabolic factors to NAFLD development, is unclear. To investigate these topics, we conducted a nationwide study examining the impact of NAFLD on hospitalization outcomes in IBD patients after adjusting for metabolic factors. METHODS: Patients with IBD-related hospitalizations were identified using the Nationwide Readmissions Database from 2016 to 2018. Inflammatory bowel disease patients with and without NAFLD were matched based on IBD type, age, sex, metabolic syndrome, and diabetes mellitus. Primary outcomes were IBD-related readmission, IBD-related surgery, and death. Secondary outcomes were length of stay (LOS) and cost of care (COC). The primary multivariable model adjusted for obesity, dyslipidemia, Charlson-Deyo comorbidity index, hospital characteristics, payer, patient income, and elective status of admissions. RESULTS: Nonalcoholic fatty liver disease was associated with a higher risk of IBD-related readmission (adjusted hazard ratio, 1.90; P < .01) and death (adjusted hazard ratio, 2.73; P < .01), 0.71-day longer LOS (P < .01), and $7312 higher COC (P < .01) in those with Crohn's disease. Nonalcoholic fatty liver disease was also associated with a higher risk of IBD-related readmission (adjusted hazard ratio, 1.65; P < .01), 0.64-day longer LOS (P < .01), and $9392 (P < .01) higher COC, but there was no difference in death in those with UC. No differences in risk of IBD-related surgery were observed. CONCLUSIONS: Nonalcoholic fatty liver disease is associated with worse hospitalization outcomes in IBD patients after adjusting for metabolic factors. These data suggest nonmetabolic factors may be implicated in the pathogenesis of NAFLD in IBD patients and may contribute to worsened clinical outcomes.

COVID-19 and Outcomes in Patients With Inflammatory Bowel Disease: Systematic Review and Meta-Analysis.

BACKGROUND: Our understanding of coronavirus disease 2019 (COVID-19) and its implications for patients with inflammatory bowel diseases (IBD) is rapidly evolving. We performed a systematic review and meta-analysis to investigate the epidemiology, clinical characteristics, and outcomes in IBD patients with COVID-19. METHODS: We searched PubMed, EMBASE, Cochrane Central, Clinicaltrials.gov, Web of Science, MedRxiv, and Google Scholar from inception through October 2020. We included studies with IBD patients and confirmed COVID-19. Data were collected on the prevalence, patient characteristics, pre-infection treatments for IBD, comorbidities, hospitalization, intensive care unit (ICU), admission, and death. RESULTS: Twenty-three studies with 51,643 IBD patients and 1449 with COVID-19 met our inclusion criteria. In 14 studies (n = 50,706) that included IBD patients with and without COVID-19, the prevalence of infection was 1.01% (95% confidence interval [CI], 0.92-1.10). Of IBD patients with COVID-19, 52.7% had Crohn's disease, 42.2% had ulcerative colitis, and 5.1% had indeterminate colitis. Nine studies (n = 687) reported outcomes according to IBD therapy received. Compared with patients on corticosteroids, those on antitumor necrosis factor (anti-TNF) therapy had a lower risk of hospitalization (risk ratio [RR], 0.24; 95% CI, 0.16-0.35; P < .01; I2 = 0%) and ICU admission (RR, 0.10; 95% CI, 0.03-0.37; P < .01) but not death (RR, 0.16; 95% CI, 0.02-1.71; P = .13; I2 = 39%). Compared with patients on mesalamine, those on antitumor necrosis factor therapy had a lower risk of hospitalizations (RR, 0.37; 95% CI, 0.25-0.54), ICU admissions (RR, 0.20; 95% CI, 0.07-0.58), and death (0.21; 95% CI, 0.04-1.00). Comparing patients on immunomodulators vs mesalamine or anti-TNF therapy, there was no difference in these outcomes. CONCLUSIONS: The prevalence of COVID-19 in IBD patients was low. Use of corticosteroids or mesalamine was significantly associated with worse outcomes, whereas use of anti-TNFs was associated with more favorable outcomes. Further investigation clarifying the mechanisms of these disparate observations could help identify risk and adverse outcome-mitigating strategies for patients with IBD.

Biologic Treatment Withdrawal: Two Sides of a Coin.

Biologic Treatment Withdrawal: Two Sides of a CoinThe advent of monoclonal antibody (biologic) therapies ushered in a wave of highly effective yet relatively safe treatments for inflammatory bowel diseases; their use predicated on assertively controlling intestinal inflammation to reduce disease-related complications has accelerated their adoption in clinical practice.1-3 However, despite the overall advantages of biologic therapies, patients often express hesitation initiating them. The concern is for fear of adverse effects (particularly, infections and malignancy), inconvenience, cost, and the psychologic barrier of having to receive an intravenous or injectable drug "for the rest of my life."

Ustekinumab is effective for perianal fistulising Crohn's disease: a real-world experience and systematic review with meta-analysis.

BACKGROUND: Perianal Crohn's disease (pCD) is a debilitating complication affecting up to 30% of Crohn's disease (CD) population, leading to increased morbidity, mortality and decreased quality of life. Despite the growing armamentarium of medications for luminal CD, their efficacy in pCD remains poorly studied. AIM: To determine the efficacy of ustekinumab, a biologic approved for luminal CD, in pCD through a retrospective cohort study and systematic review. METHODS: A retrospective cohort study on patients with CD with active perianal fistulae treated with ustekinumab from September 2013 to August 2019 was performed to determine perianal fistula response and remission at 6 and 12 months after ustekinumab induction. A systematic review was performed to further establish rates of fistula response and remission with ustekinumab. RESULTS: At 6 months, 48.1% (13/27) patients achieved fistula response with none achieving fistula remission on provider exam, and 59.3% (16/27) achieved patient-reported symptomatic improvement with 3.7% (1/27) achieving symptomatic remission. At 1 year, on provider exam, 55.6% (5/9) had fistula response with none achieving fistula remission, and 100% (9/9) had symptomatic improvement with 22.2% (2/9) achieving symptomatic remission. There were no major safety signals during 1-year follow-up. The systematic review of 25 studies found 44% (92/209) of patients with active perianal fistulas had a clinical response within 6 months of follow-up, and 53.9% (85/152) of patients with 12 months of follow-up achieved clinical response. CONCLUSION: Ustekinumab presents a safe and effective therapy for treatment of pCD. Prospective, randomised trials are needed to further elucidate long-term efficacy of ustekinumab for pCD.

The Age of Artificial Intelligence: Use of Digital Technology in Clinical Nutrition.

PURPOSE OF REVIEW: Computing advances over the decades have catalyzed the pervasive integration of digital technology in the medical industry, now followed by similar applications for clinical nutrition. This review discusses the implementation of such technologies for nutrition, ranging from the use of mobile apps and wearable technologies to the development of decision support tools for parenteral nutrition and use of telehealth for remote assessment of nutrition. RECENT FINDINGS: Mobile applications and wearable technologies have provided opportunities for real-time collection of granular nutrition-related data. Machine learning has allowed for more complex analyses of the increasing volume of data collected. The combination of these tools has also translated into practical clinical applications, such as decision support tools, risk prediction, and diet optimization. SUMMARY: The state of digital technology for clinical nutrition is still young, although there is much promise for growth and disruption in the future.

Fish Oil for Inflammatory Bowel Disease: Panacea or Placebo?

Dietary supplements have increasingly gained popularity over the years not only to replete micronutrient deficiencies but for their use in treatment of disease. The popularity of dietary supplements for inflammatory bowel diseases (IBD) arises from their perceived ease of use, potential disease-modifying benefits, and perceived safety. Overall, randomized controlled trials have not consistently shown a benefit of fish oil for the maintenance of remission with Crohn's disease. The inconsistency of these findings highlights the need for more studies that are powered to clarify the context in which omega-3 fatty acids might have a role in the treatment algorithm of IBD.

Rates of inflammatory bowel disease in Hispanics comparable to non-Hispanic Whites: results of a cohort study.

PURPOSE: Previous studies have suggested that inflammatory bowel disease (IBD) occurs at higher rates among non-Hispanic Whites (NHWs) compared to other ethnicities; however, Hispanics as the largest minority in the United States remain underrepresented in IBD research and we hypothesize that they have similar rates of IBD. We examined the epidemiology, demographics, clinical presentation, and treatment of IBD in a predominantly Hispanic cohort in Los Angeles (LA) County. METHODS: This was a retrospective cohort study based at Olive View-UCLA Medical Center, one of the three major safety-net hospitals in LA County. Electronic medical records from 2015 to 2018 were queried, and biopsy-proven cases of IBD (n = 170) were identified. Outcomes included the incidence and prevalence of IBD, disease distribution, treatment, and IBD-related surgery. RESULTS: The incidence of IBD among Hispanics was 175 (95% confidence interval [CI] 127-240) and 113 (95% CI 62-200) for NHWs per 100,000 person-years. Prevalence of IBD per 100,000 people was 418 (95% CI 341-512) for Hispanics and 557 (95% CI 431-739) for NHWs. Notably, the proportion of Hispanic IBD patients with a history of smoking was 21.5% vs 50.8% in NHWs (p = 0.011). There were no significant differences between the two groups with regard to Montreal classification, pharmacotherapy, or IBD-related surgery. CONCLUSIONS: In one of the largest US studies of Hispanics with IBD, and the only one to have both clinical and histopathologic confirmation as inclusion criteria, we found the incidence and prevalence of IBD among Hispanics to be higher than previously recognized and comparable to NHWs. Additionally, Hispanic IBD patients had lower rates of smoking compared to NHWs.

Serrated Epithelial Change Is Associated With High Rates of Neoplasia in Ulcerative Colitis Patients: A Case-controlled Study and Systematic Review With Meta-analysis.

BACKGROUND: Patients with long-standing ulcerative colitis (UC) are at an increased risk of colorectal cancer. Risk stratification is important to identify patients who require more frequent endoscopic surveillance. Serrated epithelial change (SEC) found in patients with long-standing colitis may be associated with neoplasia and serve as a marker to stratify patients at higher risk of colorectal cancer (CRC). METHODS: A case-control study was performed to compare the rates of neoplasia between UC patients with SEC and UC patients without SEC who were matched for age, disease duration, and disease extent. Paired tests, conditional logistic regression, and Kaplan-Meier analyses were used to compare groups. A systematic review with meta-analysis was performed, combining our local data with previously published data. RESULTS: This study included 196 UC patients without prior neoplasia, 98 with SEC and 98 without SEC. Ulcerative colitis patients with SEC had a significantly higher rate of synchronous or metachronous neoplasia than UC patients without SEC (26.5% vs 3.1%; P < 0.001). Synchronous or metachronous high-grade dysplasia and CRC were found more frequently in UC patients with SEC than UC patients without SEC (11.2% vs 2.0%; P = 0.02). A meta-analysis was consistent with these findings, showing a higher rate of neoplasia in patients with SEC compared with those without SEC (16.4% vs 3.9%; P < 0.001). CONCLUSION: Serrated epithelial change is associated with a significantly increased risk of synchronous and metachronous neoplasia including high-grade dysplasia and CRC in patients with UC. Histopathological findings of SEC should warrant closer endoscopic surveillance for CRC.