Treatment of inflammatory bowel diseases: focusing on 5-aminosalicylates and immunomodulators

Background: Recently, the incidence and prevalence rates of inflammatory bowel disease (IBD) have increased worldwide, including in Korea. Although there has been considerable progress in the management of IBD following the discovery of biologic agents, 5-aminosalicylate (5-ASA) and immunomodulators are still considered cornerstones in the management of mild to moderate IBD.Current Concepts: 5-ASA plays a key role in inducing remission in patients with mild to moderate ulcerative colitis. High doses of 5-ASA are more effective in inducing remission in patients with moderate ulcerative colitis, and combination therapy of oral 5-ASA and topical 5-ASA agents is recommended. Although the effect of 5-ASA in patients with Crohn disease is limited, high doses of 5-ASA can be effective for patients with mild disease, inflammatory behavior, and colonic involvement. Maintaining remission is essential for patients with IBD. Good doctor-patient relationships and encouraging drug adherence are recommended. Regarding drug adherence, a once-daily regimen is preferred for patients’ satisfaction. Thiopurines, the most important immunomodulators, show therapeutic benefits, such as steroid-sparing effects and remission maintenance in ulcerative colitis and Crohn disease after induction therapy. However, several side effects, including severe leukopenia, can induce the discontinuation of thiopurines. Close monitoring and management decisions should be individualized according to the risk of relapse and adverse events.Discussion and Conclusion: In conclusion, 5-ASA and immunomodulators are cornerstones in the management of IBD. As such, clinicians should have knowledge of these drugs and patients’ characteristics for proper prescription.

The risk factors for complications after Crohn’s Disease surgery .

Background: Crohn’s disease needs a multidisciplinary approach and surgery will ultimately be necessary for most patients. Complications usually occur after surgery. Objective : This study aims to present complication rates in surgically treated Crohn's disease patients at a single institution and to determine possible risk factors. Methods: A retrospective analysis of 112 consecutive surgery performed on Crohn’s disease patients between 2003 and 2015. The demographic data, patient and disease characteristics, surgery type, and complications were analyzed. Results: Of 112 patients, 64 (57.1%) were male and 48 (42.9%) were female. The mean age was 34 (18-78) years. The mean follow-up was 114±32.4 (61-197) months. The most common early complications were intra-abdominal abscess formation (n=10, 8.9%) and wound infection (n=7, 6.26%). The incisional hernia was the most common late complication (n=4, 3.6%). Non-modifiable disease features associated with complications were colonic involvement of the disease (p=0.001), penetrating disease character (p=0.037), stoma formation (p=0.000), fistula (p=0.008) and concomitant fistula and intra-abdominal abscess (p=0.043) existence. Stoma formation was found to be an independent risk factor for complications (p=0.001). Conclusions: Colonic involvement, penetrating disease, fistula, concomitant abscess and fistula, and stoma formation were identified as non-modifiable risk factors for complications after surgery for Crohn’s disease.

Intra-abdominal fibroid lesion of colonic involvement

Fibroid is a benign lump of growth, occurring within or outside the uterus. It is a rarity for such growths to occur intra-abdominally. Such cases are of aggressive fibromatosis which are marked by the presence of desmoid tumours. It is most commonly seen in patients with a history of familial adenomatous polyposis (FAP) or past surgical procedures. As FAP has a wide fibroepithelial growth spectrum, the symptomatology and therefore the prognosis varies. Unpredictable clinical behaviour, varied location and non-specific presentation are the factors accounting to diagnostic difficulty. Therefore, misdiagnosing the disease is not uncommon. Here we report a case ofa26-year-old pregnant female presenting with lower abdominal pain and mass. Preoperative diagnosis was of uterine fibroids as per radiological evidence, but on exploration it turned out to be a large right colonic mass. The patient underwent right hemicolectomy. Histopathological reports confirmed morphological and immuno-histochemical features indicating fibromatosis. This fibromatous mass though intra-abdominal was not growing from the mesentery/mesocolon or the pelvis. It appeared to grow from the wall of the colon. This is a confirmatory presentation of true colonic wall fibromatosis which is deep and isolated form of intra-abdominal desmoid tumours. As this lesion was isolated in nature, the treatment of choice was surgical resection. It is essential to have a multi-disciplinary team approach in the management of such a patient. This improves the treatment and the prognostic outcomes. Keywords: Fibroid, Colon, Fibromatosis, Hemicolectomy, Desmoid Tumour

P600 Real-world clinical characteristics and therapeutic strategies in patients with moderate-to-severe Inflammatory Bowel Disease in Argentina: Data from the RISE AR study

Background Evidence on the adoption of different pharmacologic strategies in inflammatory bowel disease (IBD) in the real-world setting in Latin America is scarce. Herein, we describe the clinical characteristics and therapeutic strategies of IBD patients (pts) in Argentina. Methods RISE AR (NCT03488030) was a multicentre, non-interventional study with a cross-sectional evaluation and a 3-year retrospective data collection period conducted in Argentina (12/2018-05/2019) to assess the use of IBD treatments. Adult pts (≥18 years old) with a previous diagnosis of moderate-to-severe ulcerative colitis (UC) or Crohn′s disease (CD) based on clinical, endoscopic or imaging criteria at least 6 months prior to enrolment, were included. Results Overall, 101 CD and 145 UC pts were included. Median (range) age (years) at enrolment was 39.5 (18.2–74.0) for CD (51.2% female) and 41.9 (18.0–80.4) for UC (55.2% female); median (range) disease duration (years) was 7.4 (0.6–36.9) for CD and 5 (0.7–33.8) for UC. At enrolment, 51.5% of CD pts had colonic involvement, 32.7% ileocolonic, 8.9% ileal, 1% isolated upper tract and 5.9% had combined L4/other. In UC, 46.2% had extensive colitis, 44.7% left-sided colitis and proctitis 9.1%. 51.6% of CD pts had non-inflammatory behaviour (37.7% stricturing; 13.9% penetrating), and 34% had perianal disease (13.9% as B1p), resulting in a total of 65.5% pts with complicated disease. Only 9.3% of CD (Harvey Bradshaw Index ≥8) and 7.7% of UC (partial Mayo Score ≥5) pts showed moderate-to-severe disease activity at enrolment. In CD, 70.3% of pts were receiving a biologic agent vs. 29.7% of UC pts. Immunosuppressant (IMM) use was similar between groups (CD 39.6%, UC 40.0%); nearly one-third of the pts on a biologic were receiving concomitant IMM (CD 33.8%, UC 34.9%). Aminosalicylates (5-ASA) were used for most UC pts (89.0%) vs. 47.5% of CD pts, mainly in those with L2 disease. 5-ASA monotherapy was prescribed in 32.1% of UC vs. 5.3% of CD pts, but were also used with IMM (UC 25%, CD 11%), biologics (UC 15%, CD 11.6%) or all three therapies combined (UC 6.4%, CD 17.9%). Corticosteroids (CS) were the least prescribed therapy (CD 7.9%, UC 13.8%). IBD treatments ever prescribed during the retrospective period were (CD, UC): biologics: 79.2%, 33.8%; IMM: 65.3%, 58.6%; 5-ASA: 62.4%, 97.9%; CS: 55.4%, 69.7%. Conclusion In this cohort of IBD patients, biologics use was high, especially among CD patients, in line with disease behaviour, and possibly by their increased availability in these reference centres. This study also highlights country-specific clinical features such as the low proportion of CD pts and the high prevalence of colonic involvement in CD.

P689 Aeromonas infection and Inflammatory Bowel Disease: a single tertiary center analysis

Background Aeromonas genus consists of gram-negative rods known to cause a spectrum of diseases in humans. Inflammatory bowel disease (IBD) is an idiopathic complex condition where multiple factors contribute to its development and progression. The association of Aeromonas infection with IBD manifestation have been proposed by other authors and is still largely unknown. We aim to look for the significance of Aeromonas infection and for significant differences between IBD and non-IBD patients. Methods A retrospective observational data retrieval and analysis was performed of all patients positive for Aeromonas in stool cultures, during a 10-year period, from a Portuguese tertiary and university setting hospital. Results Fifty patients, 56% of male sex and with a mean age of 42.1 years-old were included. Thirty-eight (76%) were non-IBD and 12 (24%) were IBD patients. IBD patients were more frequently under immunosuppressors. Two patients were asymptomatic and 44% develop mild, 44% moderate and 16.7% severe infection. The main Aeromonas strains isolated were Aeromonas hydrophila/caviae. Co-isolation with other bacteria was found in 4 non-IBD patients and histological findings compatible with Cytomegalovirus were found in 2 IBD patients. Non-IBD patients presented more frequently with fever and IBD patients with bloody diarrhea and abdominal pain. There was higher tendency for severe infection rate in IBD patients with higher antimicrobial therapy use. Steroids were exclusively used in IBD group. No significant differences were observed for isolation of Aeromonas resistant strains. From the IBD, 4 patients had the diagnosis of Ulcerative Colitis and 9 of Crohn’s Disease with colonic involvement. Of them 5 patients received the diagnosis after the acute episode of Aeromonas infection. Conclusion Clinical presentation of Aeromonas infection differ between IBD and non-IBD patients. Non-IBD patients had milder severity of infection with less use of antibiotics. Aeromonas infection seem to play an important role on the contribution of IBD manifestation.