IBD Watch^®

^{Timely Information for Practicing Physicians}

May 2007

INFLAMMATORY BOWEL DISEASE (IBD)

Incidence of Clostridium difficile infection. Rodemann and others analyzed hospital admissions at the Washington University School of Medicine in St Louis, Missouri, from 1998 to 2004 and found that the incidence of C difficile infection had increased in patients with IBD, more than doubling in those with Crohn’s disease (CD; from 9.5 to 22.3 per 1,000 admissions) and tripling in those with ulcerative colitis (UC; from 18.4 to 57.6 per 1,000 admissions). The median time from admission to a positive C difficile test was usually less than 48 hours, indicating that most infections were acquired before hospitalization. In a second study, Issa and colleagues found that, among patients with C difficile infection, the proportion with IBD increased at their institution (The Medical College of Wisconsin), from 7% in 2004 to 16% in 2005 (P <0.01). Most patients (76%) contracted the infection as outpatients, most required hospitalization, and 20% of patients required colectomy. Multivariate analysis identified immunomodulator use and IBD colonic involvement as risk factors for C difficile infection. Increased vigilance for C difficile infection in patients with IBD and colitis is warranted. (Rodemann JF, et al. Clin Gastroenterol Hepatol 2007;5:339–344; Issa M, et al. Clin Gastroenterol Hepatol 2007;5:345–351.)

Pitfalls in interpretation of non-neoplastic mucosal biopsy specimens. Yantiss and Odze provide a summary of common diagnostic problems encountered by the pathologist and gastroenterologist when evaluating patients with diarrhea in whom IBD is suspected. Notably, CD and UC may have overlapping endoscopic and pathologic features. UC may show CD-like details or characteristics such as rectal-sparing, discontinuous disease, aphthous ulcers, ileal or extracolonic involvement, and granulomatous inflammation. Conversely, CD may present with diffuse, superficial pancolitis with ileal sparing that mimics the appearance of UC. In addition, other forms of colitis may show IBD-like changes on mucosal biopsy. The potential diagnostic pitfalls and features that aid in the distinction among these entities are discussed. (Yantiss RK, Odze RD. Am J Gastroenterol 2007;102:890–904.)

Risk factors for colorectal neoplasia. Jess and coworkers conducted a nested case-control study to identify risk and protective factors for colorectal dysplasia and cancer in patients with IBD in two well-described cohorts from Copenhagen County , Denmark , and Olmsted County , Minnesota . Primary sclerosing cholangitis, percentage of disease course with clinically active disease, and ³1 year of continuous symptoms were associated with neoplasia. In addition, a borderline association between neoplasia and median number of small bowel x-rays was identified. A protective effect was not observed with the frequency of physician visits, number of colonoscopies, cumulative dose of sulfasalazine or mesalamine, or partial intestinal resection. (Jess T, et al. Am J Gastroenterol 2007;102:829–836.)

Ethical issues concerning therapeutic studies. Tremaine and Camilleri discuss ethical issues for the physician who undertakes involvement in clinical treatment trials for IBD. Ethical issues include therapeutic misconception, clinical equipoise, and financial and nonfinancial conflicts of interest. The authors suggest that physicians who refer patients with IBD to enroll into treatment studies and investigators who conduct studies consider measures to clarify the separation between clinical care and participation in a therapeutic trial. The ethical treatment of patients must be ensured through measures such as the payment of participants to emphasize that the research study is different from clinical care, consent by an investigator other than the treating physician, and disclosure of conflicts of interest to the patient and the medical community in presentations and publications. The authors emphasize that if financial conflict is too great a physician should not participate in the clinical trial. (Tremaine WJ, Camilleri M. Inflamm Bowel Dis 2007 Mar 12 [Epub ahead of print])

CROHN’S DISEASE

Long-term outcome after corticosteroid-induced remission. Despite an initial clinical response, many patients with CD become steroid dependent or require further steroid treatment in the long term. Papi and colleagues followed 75 patients with CD after a corticosteroid-induced remission for 12 months to assess the probability of further steroid treatment. A total of 26 patients (34.6%) developed moderate to severe relapse requiring further steroid treatment. The cumulative probability of remaining free from steroids at 3, 6, 9, and 12 months was 93.3%, 82.6%, 78.6%, and 66.6%, respectively. Multivariate analysis identified increased C-reactive protein levels at steroid weaning and penetrating complications to be independent risk factors for further steroid requirement (P = 0.001 and 0.005, respectively). (Papi C, et al. Am J Gastroenterol 2007;102:814–819.)

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