Significant variation in recommendation of care for women of reproductive age with ulcerative colitis postileal pouch-anal anastomosis.

BACKGROUND AND AIM: Ileal pouch-anal anastomosis (IPAA) is the preferred surgical option for treatment refractory ulcerative colitis. Infertility risk post IPAA and sphincter injury concerns with vaginal delivery has led to a lack of consensus regarding timing and recommended mode of delivery (MOD) post-IPAA. To better understand these issues, we surveyed gastroenterologists (GI), colorectal surgeons (CRS), and obstetricians (OB) to assess practice variation in recommendations for delivery post IPAA. METHODS: Clinical vignettes were developed to assess knowledge, attitudes, and beliefs surrounding (1) the impact of IPAA on fertility, (2) IPAA timing around pregnancy, (3) recommended MOD after IPAA and (4) which specialist should advise on MOD. These were emailed to providers using specialty society address lists. Univariate analyses tested differences among groups. RESULTS: A total of 244 GI, 158 CRS and 39 OBs responded to the survey. The majority of GI (67%) and CRS (60%) quoted fertility reduction of >20% post-IPAA versus 11% OB (p < 0.001). More GI than CRS (67 vs. 45%) recommended delaying IPAA until after pregnancy (p < 0.001), and this was more commonly suggested by CRS in practice <10 years (p = 0.01) and <45 years old (p = 0.003). Vaginal delivery was recommended post-IPAA in 43, 20 and 57% for GI, CRS and OB, respectively (p < 0.001). Only 28% CRS versus 59% OB thought OB should primarily advise on MOD (p < 0.001). CONCLUSIONS: There is significant intra- and inter-group variation in management of women post-IPAA. There is need for consensus among subspecialists involved in managing women with this complex condition.

Association between early adverse life events and irritable bowel syndrome.

BACKGROUND & AIMS: Although childhood and adult abuse are more prevalent among patients with irritable bowel syndrome (IBS) than healthy individuals (controls), other types of early adverse life events (EALs) have not been well characterized. We investigated whether different types of EALs, before age 18 years, are more prevalent among patients with IBS, and the effects of sex and nongastrointestinal symptoms on the relationship between EALs and IBS. METHODS: EALs were evaluated in 294 IBS patients (79% women) and 435 controls (77% women) using the Early Trauma Inventory Self-Report Form, which delineates subcategories of general trauma and physical, emotional, and sexual abuse. Validated questionnaires assessed gastrointestinal, psychological, and somatic symptoms. RESULTS: Compared with controls, IBS patients reported a higher prevalence of general trauma (78.5% vs 62.3%), physical punishment (60.6% vs 49.2%), emotional abuse (54.9% vs 27.0%), and sexual events (31.2% vs 17.9%) (all P < .001). These significant differences were observed mainly in women. Of the EAL domains, emotional abuse was the strongest predictor of IBS (P < .001). Eight of the 27 EAL items were significant (P < .001) and increased the odds of having IBS by 108% to 305%. Although EALs and psychological variables were related, EALs had an independent association with IBS (P = .04). CONCLUSIONS: Various types of EALs are associated with the development of IBS-particularly among women. Psychological distress and somatic symptoms might contribute to this relationship. When appropriate, EALs and nongastrointestinal symptoms should be assessed in IBS patients.

Optimizing 6-mercaptopurine and azathioprine therapy in the management of inflammatory bowel disease.

The thiopurine drugs, 6-mercaptopurine (6-MP) and azathioprine, are efficacious in the arsenal of inflammatory bowel disease (IBD) therapy. Previous reports indicate that 6-thioguanine nucleotide (6-TGN) levels correlate with therapeutic efficacy, whereas high 6-methylmercaptopurine (6-MMP) levels are associated with hepatotoxicity and myelotoxicity. Due to their complex metabolism, there is wide individual variation in patient response therein, both in achieving therapeutic drug levels as well as in developing adverse reactions. Several strategies to optimize 6-TGN while minimizing 6-MMP levels have been adopted to administer the thiopurine class of drugs to patients who otherwise would not tolerate these drugs due to side-effects. In this report, we will review different approaches to administer the thiopurine medications, including the administration of 6-mercaptopurine in those unsuccessfully treated with azathioprine; co-administration of thiopurine with allopurinol; co-administration of thiopurine with anti-tumor necrosis factor α; 6-TGN administration; desensitization trials; and split dosing of 6-MP.

Cytomegalovirus Reactivation in Ulcerative Colitis Patients.

Ulcerative colitis (UC) patients are believed to have an increased risk for the colonic reactivation of cytomegalovirus (CMV) infection due to both inherent and iatrogenic factors. Numerous studies and case reports have described CMV infection as complicating the disease course of ulcerative colitis patients; the existing evidence suggests an association between the presence of CMV infection and increased colectomy and mortality rates in UC patients. Whether CMV is nonpathogenic with a tropism towards areas of dysplasia and inflammation in the colon of UC or plays an active role in pathogenesis is still debated. In this paper, we examine the existing evidence for the diagnosis and management of CMV infection in UC patients.