Risk Factors for Developing Hidradenitis Suppurativa in Patients With Inflammatory Bowel Disease: A Retrospective Case-Control Study.

BACKGROUND: Hidradenitis suppurativa (HS) is associated with inflammatory bowel disease (IBD), though risk factors remain to be determined. AIM: To characterize HS among a cohort of IBD patients and identify risk factors for its development. METHODS: This was a retrospective case-control study at the ambulatory IBD centre at Mount Sinai Hospital from inception to May 2019. Patients with IBD who developed HS were included. Cases were matched 5:1 by age, gender (male versus female) and IBD type (ulcerative colitis [UC] or Crohn's disease [CD]) to controls who had IBD without HS. Conditional logistic regression was used to calculate odds ratios (ORs) with 95% confidence intervals (95% CIs). RESULTS: Twenty-nine cases of HS (19 CD and 10 UC) and 145 controls were included. Of the 29 patients with HS, 11 (37.9%) were male and 18 (62.1%) were female. The severity of HS was mild in 10 (34.5%), moderate in 16 (55.2%) and severe in 3 (10.3%) patients. Patients with HS and IBD were more likely to be active (OR 10.3, 95% CI 2.0 to 54.0, P = 0.006) or past (OR 8.4, 95% CI 2.7 to 25.8, P < 0.005) smokers. Patients with HS and IBD were also more likely to have active endoscopic disease (OR 3.8, 95% CI 1.2 to 12.2, P = 0.022). Furthermore, those with HS and CD were more likely to have active perianal disease (OR 21.1, 95% CI 6.2 to 71.9, P < 0.005). CONCLUSIONS: Active IBD, perianal disease and smoking may be associated with HS in IBD. Larger studies are needed to better characterize this morbid condition.

Myoclonus Associated with Celiac Disease Responsive to Anti-Epileptics and a Gluten-Free Diet.

We report on the case of a 61-year-old male who initially presented with a progressive myoclonus and an intention tremor and was subsequently diagnosed with celiac disease. His neurological symptoms improved with anti-epileptic therapy and a gluten-free diet. Possible explanations include a milder disease phenotype or an epileptic component to his myoclonic movement disorder. This case highlights findings of a progressive myoclonic movement disorder, likely linked to celiac disease, and stresses the importance of a gluten-free diet in the management of the neurological manifestations of celiac disease.

Development of Entrustable Professional Activities for Advanced Inflammatory Bowel Disease Fellowship Training in the United States.

BACKGROUND: The level of inflammatory bowel disease (IBD) training in general gastroenterology fellowship is often insufficient to prepare trainees to deliver advanced IBD care in practice. Advanced IBD fellowships have been developed to fill this training gap, but there is no established curriculum, and significant variability exists across programs. Entrustable professional activities (EPAs) are practical and realistic objectives that define essential tasks of a specialty that physicians should master to be competent during independent practice. The American College of Gastroenterology (ACG) and Crohn's & Colitis Foundation (Foundation) established a task force to develop and appraise EPAs for advanced IBD fellowship. METHODS: Entrustable professional activities were developed using a multistep approach in a similar manner to other specialties. Initial EPAs identified via focus groups were evaluated, critiqued, and changed using an iterative model of feedback. The final EPAs were selected after the task force conducted a 3-phase modified Delphi method consisting of 2 sequential rounds of web-based voting and an in-person consensus meeting. RESULTS: Ten EPAs for advanced IBD fellowship were established including detailed descriptions with the associated knowledge, skills, and attitudes for each that can serve as curricular milestones. CONCLUSION: Ten EPAs describing the core work of an advanced IBD fellowship-trained physician have been established by a multisociety task force. Creating EPAs for an advanced curriculum comes with unique challenges, particularly the need to prevent duplication of prior training competencies while demonstrating the potential for unique milestones.

Home vs Hospital Infusion of Biologic Agents for Patients With Inflammatory Bowel Diseases.

Inflammatory bowel disease (IBD) therapy often requires biologic medications delivered by intravenous infusion.1-4 Historically, intravenous infusions of infliximab and vedolizumab in patients with IBD were delivered under direct supervision of clinicians in infusion centers at hospitals or clinics. Recently, intravenous infusions have transitioned into patient homes. Professional societies have differed on their recommendations for biologic home infusions (HI),5,6 yet limited data exist on the safety and efficacy of HI programs.7,8 Therefore, the primary aim of this study was to compare adverse outcomes (AOs), as defined as a composite of stopping therapy, IBD-related emergency-room (ER) visit, or IBD-related hospitalization, in patients with IBD receiving biologics as HI or at a hospital-based infusion center.

Emergent colectomy rates decreased while elective ileal pouch rates were stable over time: a nationwide inpatient sample study.

PURPOSE: Despite advances in biologic therapy, approximately 10-15% of ulcerative colitis (UC) patients require surgery. We aimed to (1) examine the rates of emergent colectomy and elective ileal pouch anal anastomosis (IPAA) over time among UC patients in the USA and (2) investigate disparities in surgery rates by patient demographics. METHODS: Data from the Nationwide Inpatient Sample (NIS) from 2000 to 2014 were analyzed. Inclusion criteria were admissions with a primary UC ICD-9-CM diagnosis code and age > 18. Emergent cases were defined as those admitted through the emergency room with an outcome ICD-9-CM code for subtotal colectomy. Elective IPAA cases were defined with an outcome ICD-9-CM code for IPAA, used as a surrogate measure of colectomy. Patient and hospital-level demographics were analyzed. Temporal trends of colectomy were analyzed utilizing joinpoint-regression analysis with calculation of annual percentage change (APC). RESULTS: A total of 470,708 admissions were included over the 14-year period. Emergent colectomy rate significantly declined (APC - 7.35%, p = 0.0002), while the rate of elective IPAA remained stable (APC - 0.21%, p = 0.8). Emergent colectomy rates declined similarly across all demographics, though not as marked among patients age 50 and older and Medicare patients. Elective IPAA rates were significantly lower among blacks and patients with public insurance. CONCLUSIONS: There has been a significant decline in emergent UC colectomy rates in the USA; however, the overall need for surgery appears unchanged given stable IPAA rates. This suggests a limited impact on overall surgery rates with a shift from emergent to elective procedures.

Inflammatory Bowel Disease Training During Adult Gastroenterology Residency: A National Survey of Canadian Program Directors and Trainees.

BACKGROUND: Clinical training in inflammatory bowel disease (IBD) is a mandated component of adult gastroenterology fellowship. This study aims to assess methods of instruction in IBD and identify priorities and gaps in IBD clinical training among residents and program directors (PDs). METHODS: Using both an online and in-person platform, we administered a 15-question PD survey and 19-question trainee survey that assessed the methods of IBD teaching and trainee perceptions of knowledge transfer of 22 IBD topics. The survey was previously developed and administered to US gastroenterology trainees and PDs. RESULTS: Surveys were completed by 9 of 14 (62.3%) PDs and 44 of 62 (71%) trainees. Both trainee years were equally represented (22 residents in each year of training). All respondents were based at university teaching hospitals with full-time IBD faculty on staff. Dedicated IBD rotations were not offered by more than half of training programs, and IBD exposure was most commonly encountered during inpatient rotations. Overall, only 14 (31.2%) trainees were fully satisfied with the level of IBD exposure during their training. Thirty-six (81.8%) trainees reported being comfortable with inpatient IBD management, whereas only 23 (52.3%) trainees reported being comfortable with outpatient IBD management. There was strong concordance between the proportion of PDs ranking an IBD topic as essential and trainee comfort in that area (Pearson's rho 0.59; P=0.004). Fewer than half of trainees reported comfort in 11 of 22 (50%) proposed IBD topics. Identified areas of deficiency included phenotypic and endoscopic classification of IBD, inpatient management of severe active IBD, perianal disease management, monitoring biologic therapy and extra-intestinal manifestations of IBD. CONCLUSIONS: Only one-third of Canadian gastroenterology trainees are fully satisfied with the level of IBD exposure under the current training model. Furthermore, several IBD topics appear to be inadequately covered during training. Our findings, which are similar to previously published US data, highlight the need for additional focus on IBD during gastroenterology residency.

Predictive models of disease burden at diagnosis in persons with adult-onset ulcerative colitis using health administrative data.

BACKGROUND: Health administrative data is increasingly used to conduct population-based health services research. A major limitation of these data for the study of inflammatory bowel diseases is the absence of detailed clinical information relating to disease burden. We used Ontario health administrative data to develop predictive models of disease burden at diagnosis in ulcerative colitis (UC) patients for future use in population-based studies of incident UC cohorts. METHODS: Through chart review, we characterized macroscopic colitis activity and extent at diagnosis in consecutive adult-onset UC patients diagnosed at The Ottawa Hospital between 2001 and 2012. We linked this cohort to Ontario health administrative data to test the capacity of administrative variables to discriminate different levels of disease activity, disease extent and the disease burden (a composite of disease extent and activity). We modelled outcomes as binary (using logistic regression) and ordinal (using proportional odds regression) variables and performed bootstrap validation of our final models. RESULTS: We tested 20 administrative variables in 587 eligible patients. The logistic model of total disease burden (severe and extensive colitis vs. all other phenotypes) showed moderate discriminatory capacity (optimism-corrected c-statistic value 0.729). Individual models of disease extent and disease activity showed poorer discriminatory capacity (c-statistic value < 0.7 for 3 of 4 models). CONCLUSIONS: Ontario health administrative data may reasonably discriminate levels of total disease burden at diagnosis in adult-onset UC patients. Our models should be externally validated before their widespread application in future population-based studies of incident UC cohorts to adjust for the confounding effects of differences in disease burden.

Perspectives on endoscopic surveillance of dysplasia in inflammatory bowel disease: a survey of academic gastroenterologists.

BACKGROUND AND STUDY AIMS: Dye-based chromoendoscopy (DBC) is the preferred method for endoscopic dysplasia surveillance in patients with inflammatory bowel disease (IBD). We sought to examine the uptake of, and perception toward DBC among academic gastroenterologists. METHODS: We conducted an online survey of academic members of the Canadian Association of Gastroenterology to assess their current dysplasia surveillance practice, uptake of DBC, and perceived barriers to adoption of DBC. RESULTS: Of the 150 physicians contacted, 49 (32.7 %) responded to the survey. The majority of respondents reported subspecialty training in IBD (71.4 %), and the median number of years in practice was 12. White-light endoscopy with random colonic biopsies was the preferred dysplasia screening method (73.5 %). Only 26.5 % of respondents routinely used DBC, despite institutional availability of over 60 %. The major barriers to adoption of DBC were concerns about procedure duration (46.9 %), concerns about cost (44.9 %), and inadequate training (40.8 %). CONCLUSION: There is low uptake of DBC for dysplasia surveillance in IBD patients among academic gastroenterologists practicing in Canada. Additional studies should be completed to determine how to improve the uptake of DBC.

Frequency and Variables Associated with Fasting Orders in Inpatients with Ulcerative Colitis: The Audit of Diet Orders-Ulcerative Colitis (ADORE-UC) Study.

INTRODUCTION: Current clinical practice guidelines suggest that patients with ulcerative colitis (UC) hospitalized because of a disease flare should be offered a normal diet, unless such a diet is not tolerated. Studies of hospitalized patients have demonstrated iatrogenic malnutrition from unjustified or inappropriate nil per os (NPO) or clear liquid diet (CLD) orders. In this study, we aim to characterize the burden of this problem in hospitalized patients with UC. METHODS: We conducted a retrospective cohort study of all patients with UC admitted to the gastroenterology service or the general internal medicine service at a tertiary, academic hospital between January 2009 and December 2014, with a length of stay between 2 and 30 days. The frequency and duration of bowel rest and CLD orders was recorded, and the number of meals missed because of these orders was assessed. NPO or CLD diet orders were considered justified if the patient had intractable nausea or vomiting, pancreatitis, bowel obstruction, toxic megacolon or were awaiting endoscopy, or if alternative enteral nutrition was provided. Clinical and demographic factors associated with unjustified underfeeding were identified. RESULTS: A total of 187 admissions among 158 patients with UC were identified during the study period and included in the final analysis. Most admissions were to the gastroenterology service (148/187, 79.1%). The mean age at admission was 35.0 years (SD = 15), and 83/158 (52.5%) were female. The median length of stay was 8 days (interquartile range = 4-12). Registered dietician consultation was obtained in only 32 admissions (17.1%), and admission weight was recorded in only 68 (36.4%) admissions. A total of 252 NPO or CLD dietary orders were encountered in 142 admissions (75.9%). Of those, 112 orders were unjustified (44%). On average, patients with unjustified NPO or CLD orders spent 3 days on an NPO or CLD diet, which corresponded to a mean of 10 missed meals. Characteristics associated with unnecessary fasting included female gender, less frequent endoscopic disease staging, less frequent escalation of therapy to prednisone and/or biologics, and admission to a non-gastroenterology service. CONCLUSIONS: There is a high burden of unjustified underfeeding among hospitalized patients with UC, particularly in patients admitted without evidence of objective disease flare. This may lead to nutritional compromise in an at-risk population, and further studies are needed to assess the nutritional impact of unjustified bowel rest on patients with UC. Our findings also suggest that targeted quality improvement interventions are needed to decrease the frequency of inappropriate bowel rest among hospitalized patients with UC.

Red Blood Cell Transfusions and Iron Therapy for Patients Presenting with Acute Upper Gastrointestinal Bleeding: A Survey of Canadian Gastroenterologists and Hepatologists.

Introduction. There is limited data evaluating physician transfusion practices in patients with acute upper gastrointestinal bleeding (UGIB). Methods. A web-based survey was sent to 500 gastroenterologists and hepatologists across Canada. The survey included clinical vignettes where physicians were asked to choose transfusion thresholds. Results. The response rate was 41% (N = 203). The reported hemoglobin (Hgb) transfusion trigger differed by up to 50 g/L. Transfusions were more liberal in hemodynamically unstable patients compared to stable patients (mean Hgb of 86.7 g/L versus 71.0 g/L; p < 0.001). Many clinicians (24%) reported transfusing a hemodynamically unstable patient at a Hgb threshold of 100 g/L and the majority (57%) are transfusing two units of RBCs as initial management. Patients with coronary artery disease (mean Hgb of 84.0 g/L versus 71.0 g/L; p < 0.01) or cirrhosis (mean Hgb of 74.4 g/L versus 71.0 g/L; p < 0.01) were transfused more liberally than healthy patients. Fewer than 15% would prescribe iron to patients with UGIB who are anemic upon discharge. Conclusions. The transfusion practices of gastroenterologists in the management of UGIB vary widely and more high-quality evidence is needed to help assess the efficacy and safety of selected transfusion thresholds in varying patients presenting with UGIB.

Perceptions and Attitudes Towards Medication Adherence during Pregnancy in Inflammatory Bowel Disease.

BACKGROUND AND AIMS: Women with inflammatory bowel disease [IBD] report concerns about medication safety during pregnancy. Adherence to IBD medications may be lower in pregnant patients as a result. The aim of this study was to assess medication adherence during pregnancy in women with inflammatory bowel disease. METHODS: Female patients of childbearing age completed a self-administered, structured survey. We collected demographic data, medication history, and self-reported adherence to IBD medications during pregnancy. We also assessed knowledge and perceptions of IBD medication safety in pregnancy. A time trade-off [TTO] analysis was done to assess health utilities for continuing or discontinuing IBD medications during pregnancy. RESULTS: A total of 204 women completed the survey [mean age was 32.8 years]. Current or previous pregnancy was reported by 101 patients [median parity 2, median gravity 1]. While pregnant or attempting to conceive, 47 [46.5%] participants reported stopping a prescribed IBD medication. Of those, 20 participants reported stopping medications without the advice of a physician. TTO analysis was completed by 31 patients. When presented with the option of continuing a potentially teratogenic medication, switching to less effective medication that is non-teratogenic, or stopping medication all together, participants consistently preferred to not remain on the most effective IBD therapy. CONCLUSIONS: Women with IBD report preference to not remain on IBD medications during pregnancy. This is driven by concerns about safety and uncertainty about teratogenic effects. Women with IBD may benefit from increased education about medication safety in pregnancy.

Severe Erosive Pill Esophagitis Induced by Crizotinib Therapy: A Case Report and Literature Review.

Previous case reports have described esophagitis thought to be secondary to crizotinib, an oral tyrosine-kinase inhibitor used in the treatment of anaplastic lymphoma kinase- (ALK-) positive non-small cell lung cancer (NSCLC). In those reports, the interval development of esophagitis was between two days and three months after initiating or reinitiating crizotinib therapy. We present a woman who developed ulcerative esophagitis ten months after beginning crizotinib therapy, which is highly unusual. We believe the provoking factor was a change in her medication administration routine, done to accommodate religious practices during the period of Ramadan. This case illustrates the mechanism of pill esophagitis and reinforces the importance of patient education when it comes to medication administration. Clinicians may consider early imaging or investigations in patients with concerning symptomatology in the context of crizotinib therapy or other offending medications. Future research may help to uncover additional risk factors for this exceedingly rare diagnosis in this patient population. Most importantly, this case highlights nonpharmacologic ways to improve tolerability and decrease adverse effects of a highly effective chemotherapeutic agent.

Pylephlebitis After Colonic Polypectomy Causing Fever and Abdominal Pain.

Pylephlebitis is a rare condition with a high mortality risk if not recognized and treated early. The most common symptoms include fever and abdominal pain, with the majority of cases manifesting with a polymicrobial bacteremia. We report an elderly woman with pylephlebitis presenting with fever, abdominal pain, diarrhea, and vomiting, likely secondary to a polypectomy 6 weeks prior. Abdominal CT revealed portal vein thrombus and blood cultures grew Streptococcus milleri and Haemophilus parainfluenza type V. Pylephlebitis should be considered when symptoms and signs of infection develop following endoscopic procedures, particularly in patients with an underlying hypercoaguable disease.

Ethnic Differences in Drowning Rates in Ontario, Canada.

The scientific literature suggests ethnicity may be a risk factor for drowning. Ontario, Canada is one of the most ethnically diverse places in the world. The objective of our study was to determine if Asians, Africans and Hispanics were at an increased risk of drowning compared to Greater Europeans. Ethnicity served as a surrogate for country of origin. Using Coroner's reports, all unintentional drowning deaths in Ontario from 2004 to 2008 were reviewed. The ethnicity of drowning victims was estimated using a previously validated name-based ethnicity classifier. Age-standardized drowning rates were calculated by sex and place of residence (rural vs. non-rural) for people of each ethnicity group using the method of direct standardization. For residents of Ontario living in rural areas, the age-standardized drowning rate was significantly higher among men of Asian, African, or Hispanic ethnicity compared to men of Greater European ethnicity (RR 13.9; 95% CI 8.1-23.8) and for women of Asian, African, or Hispanic ethnicity compared to women of Greater European ethnicity (RR 23.9; 95% CI 6.4-89.1). These high-risk individuals need to be considered when developing drowning prevention strategies.

Practices and attitudes toward complementary and alternative medicine in inflammatory bowel disease: a survey of gastroenterologists.

BACKGROUND: Use of complementary and alternative medicine (CAM) is increasingly prevalent among patients with inflammatory bowel disease (IBD). We sought to characterize the practices and attitudes of IBD physician providers toward CAM. METHODS: A web-based survey was sent to non-trainee physician members of the American Gastroenterological Association with an interest in IBD. The survey included multiple-choice and Likert scale questions which queried physician perceptions of CAM and their willingness to discuss CAM with patients. RESULTS: The vast majority of respondents (80%) considered themselves IBD subspecialists with 75% holding academic appointments. Nearly a third reported initiating conversations on CAM in the majority of their patient interactions, while 90% perceived that a majority of their patients were reluctant to bring up the topic of CAM. Nearly three quarters (72%) of respondents felt comfortable discussing CAM, while those that did not most frequently cited lack of knowledge as the reason. More than half (55%) stated they had no systematic approach to discussing CAM. Most gastroenterologists (65%) reported no formal training in CAM. Most gastroenterologists had recommended use of probiotics, and nearly half had recommended acupuncture. A vast majority believed that there was adjunctive role for CAM in treatment of IBD. CONCLUSIONS: Academic IBD specialists were receptive to the use of CAM, and most felt that it had a role in the treatment of IBD, without necessarily compromising conventional therapy. Formal educational initiatives and societal recommendations on the use of CAM may facilitate a more systematic approach to its use in daily practice.

Colorectal cancer in inflammatory bowel disease: a shift in risk?

Patients with inflammatory bowel disease are at an increased risk for the development of colorectal cancer. However, the magnitude of this risk may not be as high as earlier studies have suggested. This shift in risk may be a result of changes in quality of analyses, aging cohorts, or may indeed represent true declines in the risk of cancer as a result of improvements in medical therapy and surveillance programs. The best surveillance practices for colorectal cancer screening in patients with inflammatory bowel disease remains unclear. The finding of dysplasia on colonoscopy in these patients warrants multi-disciplinary consultation between endoscopist, pathologist, and patient. At present, major organizations offer guidelines for surveillance interval, as well as when surgical consultation is advised. Moreover, newer endoscopic technologies have been developed and their incorporation into dysplasia surveillance programs continues to evolve.

Allergic sensitization in Canadian chronic rhinosinusitis patients.

BACKGROUND: Chronic rhinosinusitis (CRS) is a societal burden and cause of morbidity in Canada; however, the prevalence of allergic sensitization in Canadian CRS patients has remained poorly characterized. OBJECTIVE: In this study, we used skin prick test (SPT) and specific immunoglobulin E (sIgE) and G (sIgG) titers to regionally relevant allergen sources in order to determine whether allergic sensitization is more prevalent in CRS patients compared to chronic idiopathic urticaria (CIU) control patients. METHODS: One hundred and fifty eight subjects (19-70 years of age) were recruited into the study. 101 subjects had a confirmed diagnostic history of CRS and 57 subjects with a clinical diagnosis of CIU were recruited as controls. Enrolled subjects underwent SPT to a panel of perennial and seasonal allergens and sIgE titers were quantified to selected environmental allergen mixes (grass, mold, and tree species) using Phadia ImmunoCAP. sIgG was additionally quantified to Alternaria alternata, Aspergillus versicolor, Cladosporium herbarum, and Stachybotrys atra. Differences between CRS and control CIU patient SPT and serological data were examined by chi-squared analysis and analysis of variance. RESULTS: Reactivity to at least one SPT extract occurred in 73% of CRS patients. Positive SPT reactivity to A. alternata (odds ratio (OR): 4.34, 95% confidence interval: 1.57, 12.02), cat (OR: 3.23, 95% CI: 1.16, 9.02), and ragweed (OR: 2.31, 95% CI: 1.02, 5.19) extracts were more prevalent in patients with CRS (p < 0.05). Although dust mite and timothy grass sensitization approached statistical significance in the chi-squared analysis of SPT data, other common perennial and seasonal allergens were not associated with CRS. No statistically significant differences were observed between mean sIgE and sIgG titers in CRS and control patients. CONCLUSIONS: This study supports previous data that suggests A. alternata sensitization is associated with CRS; however, these findings additionally highlight the contribution of other regionally important allergens including cat and ragweed.

A survey of perceptions and practices of complementary alternative medicine among Canadian gastroenterologists.

BACKGROUND: Despite a high prevalence of complementary alternative medicine (CAM) use among inflammatory bowel disease (IBD) patients, there is a dearth of information about the attitudes and perceptions of CAM among the gastroenterologists who treat these patients. OBJECTIVE: To characterize the beliefs, perceptions and practices of gastroenterologists toward CAM use in patients with IBD. METHODS: A web-based survey was sent to member gastroenterologists of the Canadian Association of Gastroenterology. The survey included multiple-choice and Likert scale questions that queried physician knowledge and perceptions of CAM and their willingness to discuss CAM with patients. RESULTS: Fifty-three per cent of respondents considered themselves to be IBD subspecialists. The majority (86%) of gastroenterologists reported that less than one-half of their patient population had mentioned the use of CAM. Only 8% of physicians reported initiating a conversation about CAM in the majority of their patient encounters. Approximately one-half (51%) of respondents were comfortable with discussing CAM with their patients, with lack of knowledge being cited as the most common reason for discomfort with the topic. Most gastroenterologists (79%) reported no formal education in CAM. While there was uncertainty as to whether CAM interfered with conventional medications, most gastroenterologists believed it could be effective as an adjunct treatment. CONCLUSION: Our findings demonstrate that gastroenterologists were hesitant to initiate discussions about CAM with patients. Nearly one-half were uncomfortable or only somewhat comfortable with the topic, and most may benefit from CAM educational programs. Interestingly, most respondents appeared to be receptive to CAM as adjunct therapy alongside conventional IBD treatment.

Presence of phthalates in gastrointestinal medications: is there a hidden danger?

Pharmaceutical companies that produce gastrointestinal (GI) medications often utilize phthalates for their ability to localize medication release. Commonly prescribed GI medications that may utilize phthalates are 5-Aminosalicylates, proton pump inhibitors, and pancreatic enzymes. Our understanding of the cumulative health effects of phthalates from medications remains unclear, and there is increasing evidence that phthalates are not harmless. Experimental studies in animals have shown that phthalates, specifically dibutyl phthalate and Di-(2-ethyl-hexyl) phthalate, have the potential to alter and/or inhibit reproductive biology and in utero development. Despite the lack of definitive human data, many cohort and cross-sectional studies demonstrate concerning associations between phthalates and poor health status, specifically developmental problems. Longitudinal studies and studies with larger sample sizes are required to determine whether phthalates actually cause negative health consequences. It is also important that physicians regularly review and discuss with patients the medicinal ingredients in their medications and supplements, specifically in pregnant woman with inflammatory bowel disease.