Risk of colorectal neoplasia according to histologic disease activity in patients with inflammatory bowel disease and colonic post-inflammatory polyps.

BACKGROUND AND AIMS: While post-inflammatory polyps (PIPs) have historically been a risk factor for colorectal neoplasia (CRN), histologic activity may explain this association. We aimed to assess the impact of histologic activity on CRN occurrence in IBD patients with colonic PIPs. METHODS: Patients with PIPs on surveillance colonoscopy at Saint-Antoine hospital between 1 January 1996 and 31 December 2020 were included and subsequent colonoscopies were assessed. Histologic IBD activity was assessed by the Nancy histologic index. Survival and Cox regression analysis were performed to assess the strength of the association of PIPs and other patient variables with progression to CRN. RESULTS: A total of 173 patients with at least two surveillance colonoscopies with PIPs at index colonoscopy were compared to a similar group of 252 patients without PIPs. In survival analysis, the presence or PIPs at index colonoscopy did not impact the risk of CRN in patients with histological inflammation (p = 0.83) and in patients without histological inflammation (p = 0.98). The risk of CRN was associated with increasing Nancy index score of 3 or 4 (HR: 4.16; 95% CI 1.50-11.52 and HR: 3.44; 95% CI 1.63-7.24), age (HR per 10-year increase: 1.37; 95% CI 1.13-1.66) and first-degree family history of colorectal cancer (HR: 5.87; v 1.31-26.26), but not PIPs (HR: 1.17; 95% CI 0.63-2.17). CONCLUSIONS: After controlling for histologic activity, PIPs do not increase the risk of CRN in IBD patients. Histologic activity rather than PIPs should be considered in the risk assessment of CRN.

Patient Adherence to Fecal Calprotectin Testing Is Low Compared to Other Commonly Ordered Tests in Patients With Inflammatory Bowel Disease.

Background: Limited data exist on adherence to fecal calprotectin (FCP) testing in patients with inflammatory bowel disease. Methods: Completion rates for patients who had at least one FCP test ordered (n = 3082) and a subgroup with C-reactive protein, complete blood count, and Clostridium difficile tests also ordered (n = 1563) were analyzed. Results: More patients completed blood than stool tests, with FCP having the poorest adherence of all tests analyzed. Older patients had higher FCP completion rates. No differences were noted in completion rates across age, gender, or ethnicity for blood tests. Conclusions: Further studies are needed to develop strategies that improve the uptake of FCP.

STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): Determining Therapeutic Goals for Treat-to-Target strategies in IBD.

BACKGROUND: The Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) initiative of the International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) has proposed treatment targets in 2015 for adult patients with inflammatory bowel disease (IBD). We aimed to update the original STRIDE statements for incorporating treatment targets in both adult and pediatric IBD. METHODS: Based on a systematic review of the literature and iterative surveys of 89 IOIBD members, recommendations were drafted and modified in 2 surveys and 2 voting rounds. Consensus was reached if ≥75% of participants scored the recommendation as 7 to 10 on a 10-point rating scale. RESULTS: In the systematic review, 11,278 manuscripts were screened, of which 435 were included. The first IOIBD survey identified the following targets as most important: clinical response and remission, endoscopic healing, and normalization of C-reactive protein/erythrocyte sedimentation rate and calprotectin. Fifteen recommendations were identified, of which 13 were endorsed. STRIDE-II confirmed STRIDE-I long-term targets of clinical remission and endoscopic healing and added absence of disability, restoration of quality of life, and normal growth in children. Symptomatic relief and normalization of serum and fecal markers have been determined as short-term targets. Transmural healing in Crohn's disease and histological healing in ulcerative colitis are not formal targets but should be assessed as measures of the remission depth. CONCLUSIONS: STRIDE-II encompasses evidence- and consensus-based recommendations for treat-to-target strategies in adults and children with IBD. This frameworkshould be adapted to individual patients and local resources to improve outcomes.

Impact of Aphthous Colitis at Diagnosis on Crohn's Disease Outcomes.

BACKGROUND: The natural history of intestinal lesions in Crohn's disease [CD] is not fully understood. Although the extent of lesions at diagnosis usually defines the extent of the disease, some lesions seen at diagnosis, particularly aphthous ulcers [AUs], may resolve before follow-up. The aim of this study was to evaluate the outcomes of CD patients with colonic AUs seen at diagnosis. METHODS: CD patients with aphthous colitis at diagnosis who had been followed since 2001 were included in a case control study matched with two groups of controls: one without colonic involvement at diagnosis and a second group with colonic lesions more severe than AUs at diagnosis. RESULTS: Seventy-five patients were included, with a median follow-up of 7.3 years [interquartile range 2.7-9.8]. Seventy-one per cent of those having a second colonoscopy at least 6 months after diagnosis were stable or healed. Medical treatments were similar between the three groups. The AU group's rate of ileal surgery was similar to those without colitis. In multivariate analysis, the independent factors associated with ileal resection were ileal involvement (odds ratio [OR]: 8.8; 95% confidence interval [CI] [7.68-33.75]; p = 0.002) and the presence of severe colitis (OR = 0.5; 95% CI [0.32-0.79], p = 0.003). The risk of ileal surgery was not influenced by the presence of aphthous colitis (OR: 0.63; 95% CI [0.37-1.1]; p = 0.1). CONCLUSION: Aphthous colitis at diagnosis seems to resolve in most patients. This suggests that these lesions are of little clinical significance and may not need to be considered prior to ileal resection in CD or when making other important therapeutic decisions.

Confounders in Adenoma Detection at Initial Screening Colonoscopy: A Factor in the Assessment of Racial Disparities as a Risk for Colon Cancer.

BACKGROUND AND AIMS: The incidence and mortality of colorectal cancer is persistently highest in Black/African-Americans in the United States. While access to care, barriers to screening, and poverty might explain these findings, there is increased interest in examining biological factors that impact the colonic environment. Our group is examining biologic factors that contribute to disparities in development of adenomas prospectively. In preparation for this and to characterize a potential patient population, we conducted a retrospective review of initial screening colonoscopies in a cohort of patients. METHODS: A retrospective review was performed on initial average risk screening colonoscopies on patients (age 45-75 years) during 2012 at three institutions. Descriptive statistics and multivariable logistic regression models were used to examine the relationship between potential risk factors and the detection of adenomas. RESULTS: Of the 2225 initial screening colonoscopies 1495 (67.2%) were performed on Black/African-Americans and 566 (25.4%) on Caucasians. Multivariable logistic regression revealed that older age, male sex, current smoking and teaching gastroenterologists were associated with higher detection of adenomas and these were less prevalent among Black/African-Americas except for age. Neither race, ethnicity, BMI, diabetes mellitus, HIV nor insurance were associated with adenoma detection. CONCLUSION: In this sample, there was no association between race and adenoma detection. While this may be due to a lower prevalence of risk factors for adenomas in this sample, our findings were confounded by a lower detection rate by consultant gastroenterologists at one institution. The study allowed us to rectify the problem and characterize patients for future trials.

Uncovered Self-Expanding Metal Stent (SEMS) Four Years After Placement for Long-Term Treatment of a Benign Colonic Obstruction.

Self-expanding metal stents (SEMS) have emerged as an alternative to surgery in the treatment of malignant colorectal obstructions. There is limited data about their use for benign colonic obstructions, especially in regards to safety and long-term patency. We present a case in which long-term SEMS placement proved to be a durable option for over 4 years in a patient with a benign colonic stricture.