Subclinical bowel inflammation increases healthcare resources utilization and steroid use before diagnosis of inflammatory bowel disease.

BACKGROUND: Previous data support that the inflammatory process underlying ulcerative colitis (UC) and Crohn's disease (CD) can start years before the diagnosis. The aim of this study was to determine if patients with an incidental diagnosis of UC or CD demonstrate an increase in healthcare utilization in the years preceding the symptomatic onset of the disease. METHODS: We performed a multicenter, retrospective, hospital-based, case-control study. Patients with an incidental diagnosis of UC or CD during the colorectal cancer screening program at 9 hospitals were included. Cases were matched 1:3 and compared separately with two control populations: one including healthy non-IBD subjects adjusted by gender, age, and date, excluding those with visits to Gastroenterology; and a second control cohort of UC/CD patients with symptomatic onset. RESULTS: A total of 124 patients with preclinical inflammatory bowel disease (IBD) were included (87 UC, 30 CD, 7 IBD unclassified; median age 56 years). Patients with preclinical IBD showed an increase in the number of visits to Primary Care up to 3 and 5 years before diagnosis (aIRR 1.59, 95% CI [1.37-1.86], p = 0.001; aIRR 1.43, 95% CI [1.24-1.67], p = 0.01) and more frequent use of steroids (aOR 2.84, 95% CI [1.21-6.69], p = 0.03; aOR 2.25, 95% CI [1.06-4.79], p = 0.04) compared to matched non-IBD healthy controls, respectively. In contrast, patients with a symptomatic onset visited Primary Care less frequently, but they had an increase in the number of visits to Emergency Department, specialist care, sick-leaves, CT/ultrasound examinations, and use of antibiotics or systemic steroids. CONCLUSIONS: There is an increased need for medical assistance and use of systemic steroids during the presymptomatic phase of IBD. These results will help in establishing new tools for early identification of IBD in the future.

Early microscopic findings in preclinical inflammatory bowel disease.

BACKGROUND: The immune response involved in the pathogenesis of Inflammatory Bowel Disease (IBD) may be present years before the diagnosis, but the characteristics of the disease during the preclinical period have been scarcely investigated. AIM: To describe the microscopic findings of preclinical IBD and its relationship with the natural history of the disease. METHODS: Medical records from all patients with an incidental diagnosis of IBD during a screening colonoscopy were included in this multicentric and retrospective study. We assessed 15 histologic items in the biopsy samples at diagnosis, and the Geboes score was calculated in patients with Ulcerative Colitis (UC). The main outcome was the development of gastrointestinal symptoms during follow-up. RESULTS: We included 110 patients (79 UC, 24 Crohn's Disease (CD) and 7 with unclassified disease). In UC the most common histologic findings were acute or chronic inflammatory infiltrate and crypt epithelial polymorphs, while in CD we observed acute or chronic neutrophilic infiltrate and epithelial irregularity. Granuloma were only observed in 4% of CD patients. Crypt distortion and the infiltration of neutrophils in the epithelium were associated with a higher risk of developing symptomatic disease. CONCLUSIONS: Preclinical IBD shows specific microscopic findings and they are associated with the progression to symptomatic disease.

Mediastinal abscess, an unusual way of presentation of eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is one of the most prevalent esophageal diseases and the leading cause of dysphagia and food impaction in children and young adults. EoE represents a chronic, local immune-mediated esophageal disease, characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. Mediastinal abscess is an uncommon condition that typically appears after esophageal perforations or thoracic surgeries, usually requiring treatment for surgical intervention due to its high morbidity-mortality. Mediastinal abscess, outside these two contexts, is extremely rare. We present the case of a mediastinal abscess secondary to EoE. It is important to think about this entity when there is a mediastinal abscess without trauma or previous surgery.

Characteristics and Progression of Preclinical Inflammatory Bowel Disease.

BACKGROUND & AIMS: Inflammatory bowel disease (IBD) is a chronic disease usually diagnosed after the appearance of gastrointestinal symptoms. Little is known about IBD progression during its early and even preclinical phases. We aimed to determine the number of new incidental diagnoses of IBD in an older population, and evaluate disease progression from its early stages. METHODS: We performed a retrospective analysis of 31,005 colonoscopies performed during colorectal cancer screening of patients with positive results from fecal immunochemical tests, at 11 centers in the Basque Country (Spain) from 2009 through 2014. We collected clinical and laboratory data from all asymptomatic individuals suspected to have IBD during screening colonoscopies, with histologic confirmation. RESULTS: Colonoscopy screening led to 79 new diagnoses of ulcerative colitis, 24 of Crohn's disease, and 7 of unclassified colitis (average patient age, 57 y; interquartile range, 52-62 y; 57% male). Eleven patients had symptoms before colonoscopy and were excluded from the analysis. Among those patients who were asymptomatic at diagnosis, 36% developed symptoms after a follow-up period of 25 months (interquartile range, 10.5-42 mo), mostly rectal bleeding and diarrhea. Treatment was prescribed for 81 patients (88%), and 2 cases required surgery. CONCLUSIONS: We analyzed data from a large cohort of patients with IBD diagnosed at early or even preclinical stages, from an older population. New incidental diagnoses of IBD were made in 0.35% of individuals undergoing a population-based screening colonoscopy-most were classified as ulcerative colitis. Approximately one third of patients developed symptoms during the follow-up period.

Enfermedad inflamatoria intestinal como efecto paradójico del tratamiento con anti-TNF-alfa / Inflammatory bowel disease as a paradoxical effect of anti-TNF alpha therapy

Los anti-TNF-α forman parte del tratamiento de distintas enfermedades inflamatorias, como la enfermedad inflamatoria intestinal (EII). Sin embargo, se han descrito los efectos paradójicos, es decir, el desenmascaramiento o producción de enfermedades similares a aquellas para las que se utilizan. Concretamente, en la EII, el fármaco biológico más implicado ha sido etanercept, el cual además no ha demostrado su utilidad como tratamiento de esta enfermedad. Esta asociación, que no es casual, y que cumple el criterio temporal de causalidad, es un cuadro infrecuente que se da especialmente en pacientes con espondiloartritis. Su reintroducción puede inducir nuevos brotes. No hay diferencias clínicas, endoscópicas ni anatomopatológicas que permitan discernirla de la EII primaria, y el proceso diagnóstico es el mismo. La presentación más habitual es la de enfermedad de Crohn. La estrategia terapéutica más extendida consiste en sustituir etanercept por infliximab, con el cual no se ha descrito recidiva de la enfermedad

Anti-TNF-α therapies are used in the treatment of different inflammatory conditions, such as inflammatory bowel disease (IBD). However, paradoxical effects may occur during treatment. In other words, these drugs can induce or unmask diseases similar to those they were intended to treat. Etanercept is the main anti-TNF-α agent associated with the development of paradoxical IBD; this drug, moreover, has no proven usefulness in the treatment of the disease. This association, which is not coincidental and meets the criteria for a temporal causal association, is infrequent and is seen particularly in patients with spondyloarthritis. Restarting treatment with etanercept may induce new intestinal symptoms. There are no endoscopic, histopathologic or clinical differences between primary and secondary IBD, and both are diagnosed in the same way. The most frequent presentation is Crohn disease. When a paradoxical event occurs, etanercept is usually replaced with infliximab, which has not been associated with disease recurrence

Inflammatory bowel disease as a paradoxical effect of anti-TNF alpha therapy. / Enfermedad inflamatoria intestinal como efecto paradójico del tratamiento con anti-TNF-α.

Anti-TNF-α therapies are used in the treatment of different inflammatory conditions, such as inflammatory bowel disease (IBD). However, paradoxical effects may occur during treatment. In other words, these drugs can induce or unmask diseases similar to those they were intended to treat. Etanercept is the main anti-TNF-α agent associated with the development of paradoxical IBD; this drug, moreover, has no proven usefulness in the treatment of the disease. This association, which is not coincidental and meets the criteria for a temporal causal association, is infrequent and is seen particularly in patients with spondyloarthritis. Restarting treatment with etanercept may induce new intestinal symptoms. There are no endoscopic, histopathologic or clinical differences between primary and secondary IBD, and both are diagnosed in the same way. The most frequent presentation is Crohn disease. When a paradoxical event occurs, etanercept is usually replaced with infliximab, which has not been associated with disease recurrence.