The use of methotrexate for treatment of inflammatory bowel disease in clinical practice.

BACKGROUND: Methotrexate is considered a treatment for Crohn's disease, whilst few data in ulcerative colitis are available. AIM: To evaluate frequency, indications, efficacy and safety of methotrexate in inflammatory bowel disease patients. METHODS: 5420 case histories were reviewed. RESULTS: Methotrexate was prescribed to 112 patients (2.1%; 89 Crohn's disease, 23 ulcerative colitis). It was the first-line immunosuppressive option in 32 (28.6%), it was an alternative drug due to toxicity or failure of thiopurines in 80 (71.4%). Steroid-dependence represented the main indication both when it was used as first (13/32, 40.6%) and second option (41/80, 51.2%). Efficacy was considered optimal in 39/112 (34.8%), partial in 29/112 (25.9%), absent in 22/112 (19.6%), not assessable in 22/112 (19.6%). Side effects happened in 49 out of 112 patients (43.7%) (39 Crohn's disease, 10 ulcerative colitis), leading to drug discontinuation in 38 (33.9%). The occurrence of side effects was approximately fivefold higher in patients who did not receive folic acid (14/19, 73.7%) than in those who did (35/93, 37.6%): odds ratio 4.64, 95% confidence interval 1.54-14.00; p=0.005. CONCLUSIONS: The use of methotrexate appears to be negligible in clinical practice. However, our results suggest that, if appropriately used, methotrexate could be more widely administered to inflammatory bowel disease patients with complicated disease.

Pre-illness changes in dietary habits and diet as a risk factor for inflammatory bowel disease: a case-control study.

AIM: To evaluate whether symptoms of inflammatory bowel disease (IBD), before diagnosis modify dietary habits, and to investigate the pre-illness diet in patients with recent IBD in comparison with an age-matched healthy control group. METHODS: Overall, 83 new cases of IBD (41 ulcerative colitis, 42 Crohn's disease) and 160 healthy controls were studied. Portions per week of 34 foods and beverages before onset of symptoms were recorded using a validated questionnaire. Duration of symptoms before IBD diagnosis, presence of specific symptoms and their impact on subjective changes in usual dietary habits were also recorded. The association between diet and IBD was investigated by multiple logistic regression and dietary patterns were assessed by factor analysis. RESULTS: Changes in dietary habits, due to the presence of symptoms, were reported by 38.6% of patients and were not significantly related to specific symptoms, rather to long duration of symptoms, only in Crohn's disease patients. In IBD patients who did not change dietary habits, moderate and high consumption of margarine (OR = 11.8 and OR = 21.37) was associated with ulcerative colitis, whilst high consumption of red meat (OR = 7.8) and high intake of cheese were associated with Crohn's disease. CONCLUSION: More than one third of IBD patients change dietary habits before diagnosis. Margarine, red meat and cheese increase the risk of ulcerative colitis and Crohn's disease.

Incidence and risk factors for gallstones in patients with inflammatory bowel disease: a large case-control study.

UNLABELLED: The risk for gallstones (GD) in inflammatory bowel diseases and the factors responsible for this complication have not been well established. We studied the incidence of GD in a cohort of Crohn's disease (CD) and ulcerative colitis (UC) patients and investigated the related risk factors. A case-controlled study was carried out. The study population included 634 inflammatory bowel disease (IBD) patients (429 CD, 205 UC) and 634 age-matched, sex-matched, and body mass index (BMI)-matched controls free of GD at enrollment, who were followed for a mean of 7.2 years (range, 5-11 years). The incidence of GD was calculated by dividing the number of events per person-years of follow-up. Multivariate analysis was used to discriminate among the impact of different variables on the risk of developing GD. The incidence rates of GD were 14.35/1,000 persons/year in CD as compared with 7.75 in matched controls (P=0.012) and 7.48/1000 persons/year in UC patients as compared with 6.06 in matched-controls (P=0.38). Ileo-colonic CD location (OR, 2.14), disease duration>15 years (OR, 4.26), >3 clinical recurrences (OR, 8.07), ileal resection>30 cm (OR, 7.03), >3 hospitalizations (OR, 20.7), multiple TPN treatments (OR, 8.07), and long hospital stay (OR, 24.8) were significantly related to GD in CD patients. CONCLUSION: Only CD patients have a significantly higher risk of developing GD than well-matched hospital controls. Site of disease at diagnosis, lifetime surgery, extent of ileal resections, number of clinical recurrences, TPN, and the frequency and duration of hospitalizations are independently associated with GD.

The long-term time trends of peptic ulcer and ulcerative colitis are interrelated.

OBJECTIVE: A birth-cohort phenomenon in the time trends of a disease indicates that exposure to relevant risk factors must have occurred during an early period of life. The aim of this study was to determine whether birth-cohort patterns are common features of ulcerative colitis, gastric ulcer, and duodenal ulcer in different countries. METHODS: The number of deaths from ulcerative colitis, gastric, and duodenal ulcer in England, Netherlands, Italy, Switzerland, United States, and Scotland were retrieved from the respective national statistics offices. The death rates from the six countries were plotted against the period of birth. Age-standardized cohort mortality ratios were calculated as a summary of the overall mortality associated with each consecutive birth-cohort. RESULTS: In all countries alike, mortality from ulcerative colitis, gastric, and duodenal ulcer increased among successive generations born during the 19th century and, after reaching a sharp peak around the turn of the 20th century, declined among generations born subsequently. The rise in mortality from gastric ulcer preceded a similar rise in mortality from duodenal ulcer by 10-20 yr, and the temporal changes of duodenal ulcer coincided with those of ulcerative colitis. CONCLUSIONS: The sudden rise of peptic ulcer disease during the 19th century and the 10-20-yr time lag between gastric and duodenal ulcer are difficult to explain based on changing infection rates with Helicobacterpylori alone. The similarity between the time trends of duodenal ulcer and ulcerative colitis suggests the influence of one or more shared risk factors.

Continued rightward shift of colorectal cancer.

PURPOSE: Previous analyses of the time trends of colorectal cancer have suggested a shift from left-sided toward right-sided cancer sites. The aim of this study was to determine whether such trends in the subsite distribution of colorectal cancer could be confirmed in hospitalization statistics similarly as in the incidence data. METHODS: The inpatient files of the Department of Veterans Affairs and the Surveillance, Epidemiology, and End Result database of the National Cancer Institute were used to study the time trends of colorectal cancer in the United States during the past three decades. Any cancer location in the rectum, sigmoid, or descending colon was defined as left-sided colorectum. RESULTS: For the period between 1970 and 2000, the data from the Department of Veterans Affairs revealed a statistically significant 16 percent increase in the proportion of proximal lesions among white males and females, as well as a 22 percent increase in black males. For the period between 1973 and 1997, the data from the Surveillance, Epidemiology, and End Result revealed a 6 percent increase in the proportion of proximal colon cancers among whites and blacks of both genders. CONCLUSIONS: The epidemiologic data confirm a rightward shift in the colonic distribution of cancer.

Occupational mortality from squamous cell carcinoma of the esophagus in the United States during 1991-1996.

The epidemiology of esophageal squamous cell cancer has remained poorly understood. The occupational distribution of this cancer may provide clues about its yet unknown etiology. Data files from the National Center for Health Statistics (NCHS) of the United States offer a unique source to study causes of death, broken down by occupation and industry. The number of deaths from esophageal cancer was retrieved from the computerized US vital statistics. Mortality by occupation or industry was expressed as standardized proportional mortality ratio (PMR), adjusted by age, gender, and ethnicity. Between 1991 and 1996, 63,717 subjects died from esophageal squamous cell carcinoma. Mortality was particularly high among nonwhites and men. The industrial and the occupational distributions shared a similar pattern. Mortality from esophageal squamous cell carcinoma occurred more frequently among subjects exposed to silica dust, such as brickmasons and stonemasons, concrete and terrazzo finishers, roofers, and construction laborers. It was also high in such industries as unspecified machinery or manufacturing and such occupations as unspecified material handlers, janitors, or cleaners. It was low in industries and occupations associated with agriculture, clergy, work in religious organizations, and textiles. In conclusion, mortality from esophageal squamous cell carcinoma appeared to be low in occupations associated with less consumption of alcohol and tobacco. It was high among occupations potentially associated with exposure to silica dust and chemical solvents or detergents.