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The COVID‐19 pandemic, secondary to SARS‐CoV‐2, has resulted in high mortality and morbidity worldwide. As inflammatory bowel disease (IBD) is a chronic disease, and most patients are on long‐term immunosuppressive agents, there is understandable concern, particularly in terms of therapy. In view of this, experts in IBD across the Asia Pacific region were invited to put together recommendations based on their experience and the currently available data. In general, most IBD therapies (with a few exceptions) can be continued safely, and the general consensus is that maintaining disease control should remain the main principle of management. In addition, social distancing measures and the appropriate use of personal protective equipment should be strictly adhered to. During the current pandemic, face‐to‐face clinic follow ups and non‐urgent procedures should be kept to a minimum., This is a concerted effort by the members of the Asian Pacific Association of Gastroenterology Inflammatory Bowel Disease (IBD) Workgroup members to provide guidance on IBD management (all‐in‐one succinct review paper) during the difficult COVID‐19 pandemic.

The Asia-Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, under the auspices of the Asia-Pacific Association of Gastroenterology with the goal of improving inflammatory bowel disease care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn's and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in conjunction with conventional treatments for ulcerative colitis and Crohn's disease in Asia. These statements also address how pharmacogenetics influences the treatments of ulcerative colitis and Crohn's disease and provides guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of inflammatory bowel disease workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing, and future revisions are likely as new data continue to emerge.

ObjectiveTo investigate the incidence of gastric cancer (GC) attributed to gastric intestinal metaplasia (IM), and validate the Operative Link on Gastric Intestinal Metaplasia (OLGIM) for targeted endoscopic surveillance in regions with low-intermediate incidence of GC.MethodsA prospective, longitudinal and multicentre study was carried out in Singapore. The study participants comprised 2980 patients undergoing screening gastroscopy with standardised gastric mucosal sampling, from January 2004 and December 2010, with scheduled surveillance endoscopies at year 3 and 5. Participants were also matched against the National Registry of Diseases Office for missed diagnoses of early gastric neoplasia (EGN).ResultsThere were 21 participants diagnosed with EGN. IM was a significant risk factor for EGN (adjusted-HR 5.36; 95% CI 1.51 to 19.0; pH. pylori. Participants with OLGIM II were also at significant risk of EGN (adjusted-HR 7.34; 95% CI 1.60 to 33.7; p=0.02). A significant smoking history further increases the risk of EGN among patients with OLGIM stages II–IV.ConclusionsWe suggest a risk-stratified approach and recommend that high-risk patients (OLGIM III–IV) have endoscopic surveillance in 2 years, intermediate-risk patients (OLGIM II) in 5 years.

Recent advancement in the understanding of the pathophysiology of inflammatory bowel disease has seen an expansion in therapeutic options. Vedolizumab, a selective α4β7 inhibitor, and ustekinumab, an IL 12/23 p40 inhibitor, have provided the much-awaited out-of-class alternatives for patients who have failed or who are intolerant to anti-Tumor Necrosis Factor (TNF) therapy. However, questions remain as to how we may best use these novel therapeutic agents. We evaluate the evidence available from randomized controlled trials and postmarketing cohort studies and discuss their safety, efficacy, and limitations, in relation to anti-TNF therapy, in optimizing the treatment outcomes.

The concept of consuming microorganisms in the treatment of a medical condition and in health maintenance has gained much attraction, giving rise to an abundance of medical claims and of health supplements. This study identified relevant clinical questions on the therapeutic use of probiotics and reviewed the literature in irritable bowel syndrome, inflammatory bowel disease, impaired intestinal immunity, liver disease, intestinal infections, and common childhood digestive disorders. Statements were developed to address these clinical questions. A panel of experienced clinicians was tasked to critically evaluate and debate the available data. Both consensus and contentious statements are presented to provide to clinicians a perspective on the potential of probiotics and importantly their limitations.

Background: Genetic variants of TPMT and NUDT15 have been reported to predict the inter-patient variability in response and toxicity profiles of patients receiving thiopurine therapy. However, the clinical utility of TPMT genotyping in guiding thiopurine doses has been questionable, in part due to underlying differences in the prevalence of TPMT variants in both Caucasian and Asian populations. Several NUDT15 variants have been associated with thiopurine-induced leukopenia, particularly in Asian cohorts. So far, none have been reported in a multiethnic Asian population. Aim: To investigate the associations between TPMT and NUDT15 variants with thiopurine-induced myelotoxicity in 129 Asian inflammatory bowel disease patients. Materials & methods: Pyrosequencing was performed to screen for TPMT and NUDT15 variants. Intracellular steady-state metabolite concentrations were quantified using liquid chromatography–tandem mass spectrometry. Results: Significant declines in nadir white blood cell, absolute neutrophil count and platelet counts were observed with increasing copy numbers of the risk T allele at NUDT15 c.415C>T locus (overall p < 0.05) within 4, 8 and 12 weeks and 6 months after thiopurine initiation. Patients with low and intermediate NUDT15 activity, as inferred from haplotype pairs, had significantly higher risks of leukopenia (p = 0.000253) and neutropenia (p = 0.002) compared with patients with normal NUDT15 activity. Conclusion: These findings highlight the critical relevance of NUDT15 pharmacogenetics in predicting for thiopurine-induced myelotoxicity and confirm the lack of significance of TPMT variants in Asian inflammatory bowel disease patients.

Summary Introduction Most studies on alternative intravenous lipid emulsion (IVLE) versus conventional IVLE have been conducted in the critically ill patients. The benefits of alternative IVLE in non-critically ill patients is uncertain. We aim to determine clinical outcome difference between alternative IVLE versus conventional IVLE in non-critically ill patients. Method All patients on parenteral nutrition (PN) from July 2007 to September 2010 were identified. Patients were stratified into two groups: conventional IVLE (soybean oil-based) and alternative IVLEs, namely MCT oil-based, olive oil-based and fish oil-containing IVLE. Result Three hundred and eighty-eight patients were included in the study. Ninety-one patients received soybean-based IVLE, 59 patients received MCT oil-based IVLE, 141 patients received olive oil-based IVLE and 97 patients received fish oil-containing IVLE. Adjusting the effect of baseline covariates in separate multiple linear/logistic regression models, there were no differences in mortality, readmission, length of stay and infection between conventional IVLE group and alternative IVLEs group, the adjusted p-value was 0.64, 0.06, 0.36 and 0.18 respectively. However, there was a significant change in day 5 CRP between these two groups (8.43 g/L (SD 112.2) vs −41.2 (SD 106.4); adjusted p-value = 0.01). There was no difference in day 5 albumin between these two group (−1.03 (SD 5.1) vs −0.1 (SD 5.3); adjusted p-value = 0.08). Conclusion Our study showed that pertinent clinical outcomes in non-critically ill patients who received either conventional IVLE or alternative IVLEs were the same. However, there was significant reduction in day-5 CRP in alternative IVLE compared to conventional IVLE.

The Asia-Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, under the auspices of the Asia-Pacific Association of Gastroenterology with the goal of improving inflammatory bowel disease care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn's and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in conjunction with conventional treatments for ulcerative colitis and Crohn's disease in Asia. These statements also address how pharmacogenetics influences the treatments of ulcerative colitis and Crohn's disease and provides guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of inflammatory bowel disease workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing, and future revisions are likely as new data continue to emerge.

Living in an urban environment may increase the risk of developing inflammatory bowel disease (IBD). It is unclear if this observation is seen globally. We conducted a population-based study to assess the relationship between urbanization and incidence of IBD in the Asia-Pacific region. Newly diagnosed IBD cases between 2011 and 2013 from 13 countries or regions in Asia-Pacific were included. Incidence was calculated with 95% confidence interval (CI) and pooled using random-effects model. Meta-regression analysis was used to assess incidence rates and their association with population density, latitude, and longitude. We identified 1175 ulcerative colitis (UC), 656 Crohn’s disease (CD), and 37 IBD undetermined (IBD-U). Mean annual IBD incidence per 100 000 was 1.50 (95% CI: 1.43–1.57). India (9.31; 95% CI: 8.38–10.31) and China (3.64; 95% CI, 2.97–4.42) had the highest IBD incidence in Asia. Incidence of overall IBD (incidence rate ratio [IRR]: 2.19; 95% CI: 1.01–4.76]) and CD (IRR: 3.28; 95% CI: 1.83–9.12) was higher across 19 areas of Asia with a higher population density. In China, incidence of IBD (IRR: 2.37; 95% CI: 1.10–5.16) and UC (IRR: 2.63; 95% CI: 1.2–5.8) was positively associated with gross domestic product. A south-to-north disease gradient (IRR: 0.94; 95% CI: 0.91–0.98) was observed for IBD incidence and a west-to-east gradient (IRR: 1.14; 95% CI: 1.05–1.24) was observed for CD incidence in China. This study received IRB approval. Regions in Asia with a high population density had a higher CD and UC incidence. Coastal areas within China had higher IBD incidence. With increasing urbanization and a shift from rural areas to cities, disease incidence may continue to climb in Asia.

The introduction of ustekinumab, an interleukin [IL]12/23 p40 inhibitor, to the therapeutic armamentarium of Crohn's disease has provided a much needed treatment option for patients who have failed conventional biologics with anti-tumour necrosis factor [TNF] and anti-integrin agents. Despite targeting two major cytokine pathways, the side effect profile of ustekinumab appears to be favourable in clinical trials. In particular, the risk of tuberculosis infection was observed to be lower than in patients who have received anti-TNF agents. The risk of non-tuberculosis mycobacterium infection, however, remains unknown. Here, we report the first case of a patient with Crohn's disease who developed Mycobacterium abscessus infection while on ustekinumab treatment.

The Asia Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, at the Asia Pacific Digestive Week conference in 2006 under the auspices of the Asian Pacific Association of Gastroenterology (APAGE) with the goal of developing best management practices, coordinating research and raising awareness of IBD in the region. The consensus group previously published recommendations for the diagnosis and management of ulcerative colitis (UC) with specific relevance to the Asia-Pacific region. The present consensus statements were developed following a similar process to address the epidemiology, diagnosis and management of Crohn's disease (CD). The goals of these statements are to pool the pertinent literature specifically highlighting relevant data and conditions in the Asia-Pacific region relating to the economy, health systems, background infectious diseases, differential diagnoses and treatment availability. It does not intend to be all-comprehensive and future revisions are likely to be required in this ever-changing field.

Background Crohn's disease (CD) is increasing in incidence and prevalence in Asia, but there is a paucity of population-based studies on risk factors for surgery in Asian patients with CD. This will be useful to identify patients who may benefit from top-down treatment. This study describes the rates of abdominal surgery and identifies associated risk factors in Singaporean patients with CD. Methods This was a retrospective observational study. The medical records of Singaporeans diagnosed with CD from 1970 to 2013 were reviewed from 8 different hospitals in Singapore. The cumulative probability of CD-related abdominal surgery was estimated using the Kaplan-Meier method. The logistic regression model was used to assess associations between independent risk factors and surgery. Results The cohort of 430 Singaporean patients with CD included 63.5% Chinese, 11.9% Malay, and 24.7% Indians, with a male to female ratio of 1.6; median follow-up was 7.3 years (range, 2.9-13.0 yr) and median age at diagnosis 30.5 years (range, 19.5-43.7 yr). One hundred twelve patients (26.0%) required major abdominal surgery: the cumulative risk of surgery was 14.9% at 90 days, 21.2% at 5 years, 28.8% at 10 years, 38.3% at 20 years, and 50.6% at 30 years from diagnosis. Of the surgical patients, 75.0% were Chinese, 10.7% Malays, and 14.3% Indians; 21.4% underwent surgery for inflammatory disease, 40.2% for stricturing disease, and 38.4% for penetrating disease. Age at diagnosis (A2 17-40 yr, OR: 2.75, 95% confidence interval [CI], 1.14-7.76), ileal disease (L1 location, OR: 2.35, 95% CI, 1.14-5.0), stricturing (B2 OR: 6.09, 95% CI, 3.20-11.8), and penetrating behavior (B3 OR: 21.6, 95% CI, 9.0-58.8) were independent risk factors for CD-related abdominal surgery. Indian patients were less likely to require surgery (OR: 0.40, 95% CI, 0.19-0.78). Conclusions Age at diagnosis, L1 location, B2, and B3 disease behavior are independent risk factors for abdominal surgery. Interestingly, despite a higher prevalence of CD in Indians, a smaller proportion of Indian patients required surgery. These findings suggest that both environmental and genetic factors contribute to the risk of surgery in Asian patients with CD.

Clinical remission has been the therapeutic goal of Crohn's disease treatment for many years. While it has helped to ameliorate the symptoms, this treatment strategy has not brought about significant changes in the need for abdominal surgery in the natural history of Crohn's disease. The advent of biological agents (biologics) has shown that it is possible to induce and maintain mucosal healing in a significant proportion of treated patients. Data is also emerging to show that this has translated to fewer instances of hospitalisation and surgery for these patients. This is a paradigm shift in the therapeutic goal of Crohn's disease treatment.

Background: Azathioprine (AZA) is widely used to treat corticosteroid (CS)-dependent IBD patients but evidence supporting its use in Asian IBD patients is limited. We evaluated the efficacy of AZA in a single-center cohort of CS-dependent Asian IBD patients. Methods: Patients treated with AZA were identified from our registry and the medical records were reviewed. Inclusion criterion was: first course of AZA and treatment duration ≥6 months. Clinical response was assessed at 6 months and classified as complete response, partial response, and nonresponse. Factors associated with response (age, gender, ulcerative colitis [UC] extent, Crohn's disease [CD] behavior, ethnicity, concomitant 5-aminosalicylates/sulfasalazine, baseline activity, disease duration, leukocyte count, mean corpuscular volume, and AZA dose) were analyzed using the chi-square or Mann–Whitney U-test. Probability of sustained remission was estimated using the Kaplan–Meier method. Differences in survival curves between factors were tested with log-rank tests. Results: Sixty-four patients were included. At baseline the median age was 37.5 (range, 15–76) years, 50% male, 59.4% Chinese, 50% CD, 50% UC, and mean CS dose 20.2 (SD 10.9) mg. At month 6, complete response was 48.4% (95% confidence interval [CI], 36.7–61.3), partial response 45.1% (95% CI, 32.8–58.3), and nonresponse 7.8% (95% CI, 2.6–17.3). Partial responders had mean CS dose reductions of 11.7 mg (95% CI, 7.2–16.4, P < 0.001). The proportion of patients with sustained remission was 0.87 (95% CI, 0.73–1.0) at 2 years, 0.76 (95% CI, 0.57–0.95) at 3 years, and 0.61 (95% CI, 0.30–0.91) at 5 years of AZA treatment. Female gender was positively associated with sustained remission. Conclusions: Our study demonstrates the short- and long-term effectiveness of AZA therapy among CS-dependent Asian IBD patients. (Inflamm Bowel Dis 2011)

Inflammatory bowel disease (IBD) is increasing in many parts of the Asia-Pacific region. There is a need to improve the awareness of IBD and develop diagnostic and management recommendations relevant to the region. This evidence-based consensus focuses on the definition, epidemiology and management of ulcerative colitis (UC) in Asia. A multi-disciplinary group developed the consensus statements, reviewed the relevant literature, and voted on them anonymously using the Delphi method. The finalized statements were reviewed to determine the level of consensus, evidence quality and strength of recommendation. Infectious colitis must be excluded prior to diagnosing UC. Typical histology and macroscopic extent of the disease seen in the West is found in the Asia-Pacific region. Ulcerative colitis is increasing in many parts of Asia with gender distribution and age of diagnosis similar to the West. Extra-intestinal manifestations including primary sclerosing cholangitis are rarer than in the West. Clinical stratification of disease severity guides management. In Japan, leukocytapheresis is a treatment option. Access to biologic agents remains limited due to high cost and concern over opportunistic infections. The high endemic rates of hepatitis B virus infection require stringent screening before initiating immune-suppressive agents. Vaccination and prophylactic therapies should be initiated on a case-by-case basis and in accordance with local practice. Colorectal cancer complicates chronic colitis. A recent increase in UC is reported in the Asia-Pacific region. These consensus statements aim to improve the recognition of UC and assist clinicians in its management with particular relevance to the region.

Background and Aim We have evaluated procalcitonin (PCT) as a diagnostic marker for bacterial gastroenteritis (GE) and as a disease activity marker in inflammatory bowel disease (IBD) patients. Methods This was a prospective single-center study performed over a 1-year period. Venous blood samples were drawn from hospitalized patients with acute GE and tested for PCT, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and total white cell count (TWC); stools from the same patients were tested for standard pathogens. Venous blood samples from patients with IBD were tested for PCT, CRP, ESR, and platelet count. The PCT level was measured using an immunofluorescent assay, with normal being defined as

Inflammatory bowel disease (IBD) was previously thought to be rare in Asia, but emerging data indicate rising incidence and prevalence of IBD in the region. The Asia Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, at the Asia Pacific Digestive Week conference in 2006 under the auspices of the Asian Pacific Association of Gastroenterology with the goal of developing best management practices, coordinating research, and raising awareness of IBD in the region. The consensus group previously published recommendations for the diagnosis and management of ulcerative colitis with specific relevance to the Asia-Pacific region. The present consensus statements were developed following a similar process to address the epidemiology, diagnosis, and management of Crohn's disease. The goals of these statements are to pool the pertinent literature specifically highlighting relevant data and conditions in the Asia-Pacific region relating to the economy, health systems, background infectious diseases, differential diagnoses, and treatment availability. It does not intend to be all comprehensive and future revisions are likely to be required in this ever-changing field.

Introduction We postulated that the oro-oral route of transmission between spouses could be an important route of transmission of Helicobacter pylori. Aims To estimate the prevalence of different genotypes of H. pylori as distinguished by the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method in our local population, and to compare the genotypes of H. pylori isolated from patients and their spouses. Methods Gastric biopsies were obtained from 183 dyspeptic patients during endoscopy. PCR for H. pylori was carried out using the uceC gene for amplification, and PCR products were digested further for RFLP analysis using the enzyme MboI. Spouses of H. pylori-positive index cases were screened for the infection using serological testing; if found to be positive serologically, endoscopy and gastric biopsies were performed for genotypic study of the micro-organism. For couples with indistinguishable H. pylori strain on RFLP with restriction endonuclease MboI, the process of RFLP was repeated with digestion of the PCR products using restriction endonuclease HhaI. Results We established our PCR technique to be 89.5% sensitive and 95.5% specific. Eighty-nine subjects were found to be H. pylori positive by PCR, and eight different genotypic strains were found according to our RFLP analysis. Two genotypes accounted for 80.8% of the cases. Sixteen of 31 spouses tested serologically for H. pylori were positive. All 13 spouses who agreed to undergo endoscopy were PCR positive for H. pylori. Five couples shared indistinguishable H. pylori genotypes, but this strain was also the commonest genotype in our local population, as based on RFLP with restriction endonuclease MboI. Further RFLP on the PCR products on these five couples using restriction endonucleases HhaI showed that the H. pylori isolated from these five couples were of different strains. Conclusion The oro-oral route of transmission between spouses is unlikely to be an important mode for H. pylori infection.

Objective The rising incidence of inflammatory bowel disease in Asia supports the importance of environmental risk factors in disease aetiology. This prospective population-based case-control study in Asia-Pacific examined risk factors prior to patients developing IBD. Design 442 incident cases (186 Crohn9s disease (CD); 256 UC; 374 Asians) diagnosed between 2011 and 2013 from eight countries in Asia and Australia and 940 controls (frequency-matched by sex, age and geographical location; 789 Asians) completed an environmental factor questionnaire at diagnosis. Unconditional logistic regression models were used to estimate adjusted ORs (aOR) and 95% CIs. Results In multivariate model, being breast fed >12 months (aOR 0.10; 95% CI 0.04 to 0.30), antibiotic use (aOR 0.19; 0.07 to 0.52), having dogs (aOR 0.54; 0.35 to 0.83), daily tea consumption (aOR 0.62; 0.43 to 0.91) and daily physical activity (aOR 0.58; 0.35 to 0.96) decreased the odds for CD in Asians. In UC, being breast fed >12 months (aOR 0.16; 0.08 to 0.31), antibiotic use (aOR 0.48; 0.27 to 0.87), daily tea (aOR 0.63; 0.46 to 0.86) or coffee consumption (aOR 0.51; 0.36 to 0.72), presence of hot water tap (aOR 0.65; 0.46 to 0.91) and flush toilet in childhood (aOR 0.71; 0.51 to 0.98) were protective for UC development whereas ex-smoking (aOR 2.02; 1.22 to 3.35) increased the risk of UC. Conclusions This first population-based study of IBD risk factors in Asia-Pacific supports the importance of childhood immunological, hygiene and dietary factors in the development of IBD, suggesting that markers of altered intestinal microbiota may modulate risk of IBD later in life.

Introduction: Gastric cancer (GC) has considerable morbidity and mortality in Singapore. As doctors play an important part in persuading patients to undergo screening, and as screening may have an important role in diagnosing early GC, we sought to determine the knowledge and attitudes of doctors towards GC and GC screening. Methods: Self-administered questionnaires were distributed to a cohort of junior doctors in Singapore General Hospital. Results: There were a total of 104 respondents; 82.5% of respondents felt that GC is common in Singapore. While most risk factors (RF) were identified correctly, knowledge of dietary RF was deficient, with only 34.3% and 36.5% realising that a high salt diet and low vegetable/fruit intake were RF, respectively. 95.1% knew that GC can be asymptomatic, but if detected early, is potentially curable (97.1%). Majority of respondents felt that GC was best diagnosed by endoscopy and the best time to diagnose it was when asymptomatic. However, only 52% of the respondents felt that screening gastroscopy was worthwhile. For those willing to pay for screening gastroscopy, the mean cost they were willing to pay was S$243. Conclusion: Our results show that while most RF of GC are well recognised, knowledge of dietary factors is deficient. There is ambivalence towards screening gastroscopy despite knowing that GC is common in Singapore and can be asymptomatic. This may be a barrier to tackling the problem of GC in Singapore. Before we recommend any GC screening programmes in the future, it may be important to optimise knowledge and change the mindsets of doctors in Singapore towards GC.

Background & Aims The incidence of inflammatory bowel disease (IBD) is increasing in Asia, but little is known about disease progression in this region. The Asia-Pacific Crohn's and Colitis Epidemiology Study was initiated in 2011, enrolling subjects from 8 countries in Asia (China, Hong Kong, Indonesia, Sri Lanka, Macau, Malaysia, Singapore, and Thailand) and Australia. We present data from this ongoing study. Methods We collected data on 413 patients diagnosed with IBD (222 with ulcerative colitis [UC], 181 with Crohn's disease [CD], 10 with IBD unclassified; median age, 37 y) from 2011 through 2013. We analyzed the disease course and severity and mortality. Risks for medical and surgical therapies were assessed using Kaplan–Meier analysis. Results The cumulative probability that CD would change from inflammatory to stricturing or penetrating disease was 19.6%. The cumulative probabilities for use of immunosuppressants or anti–tumor necrosis factor agents were 58.9% and 12.0% for patients with CD, and 12.7% and 0.9% for patients with UC, respectively. Perianal CD was associated with an increased risk of anti–tumor necrosis factor therapy within 1 year of its diagnosis (hazard ratio, 2.97; 95% confidence interval, 1.09–8.09). The cumulative probabilities for surgery 1 year after diagnosis were 9.1% for patients with CD and 0.9% for patients with UC. Patients with CD and penetrating disease had a 7-fold increase for risk of surgery, compared with patients with inflammatory disease (hazard ratio, 7.67; 95% confidence interval, 3.93–14.96). The overall mortality for patients with IBD was 0.7%. Conclusions In a prospective population-based study, we found that the early course of disease in patients with IBD in Asia was comparable with that of the West. Patients with CD frequently progress to complicated disease and have accelerated use of immunosuppressants. Few patients with early stage UC undergo surgery in Asia. Increasing our understanding of IBD progression in different populations can help optimize therapy and improve outcomes.

AGA Poster session Abstract (Su1301) Digestive Disease Week (DDW), May 16-19, 2015, Washington DC

Background & Aims Inflammatory bowel diseases (IBD) are becoming more common in Asia, but epidemiologic data are lacking. The Asia-Pacific Crohn's and Colitis Epidemiology Study aimed to determine the incidence and phenotype of IBD in 8 countries across Asia and in Australia. Methods We performed a prospective, population-based study of IBD incidence in predefined catchment areas, collecting data for 1 year, starting on April 1, 2011. New cases were ascertained from multiple overlapping sources and entered into a Web-based database. Cases were confirmed using standard criteria. Local endoscopy, pathology, and pharmacy records were searched to ensure completeness of case capture. Results We identified 419 new cases of IBD (232 of ulcerative colitis [UC], 166 of Crohn's disease [CD], and 21 IBD-undetermined). The crude annual overall incidence values per 100,000 individuals were 1.37 for IBD in Asia (95% confidence interval: 1.25−1.51; 0.76 for UC, 0.54 for CD, and 0.07 for IBD-undetermined) and 23.67 in Australia (95% confidence interval: 18.46−29.85; 7.33 for UC, 14.00 for CD, and 2.33 for IBD-undetermined). China had the highest incidence of IBD in Asia (3.44 per 100,000 individuals). The ratios of UC to CD were 2.0 in Asia and 0.5 in Australia. Median time from symptom onset to diagnosis was 5.5 months (interquartile range, 1.4−15 months). Complicated CD (stricturing, penetrating, or perianal disease) was more common in Asia than Australia (52% vs 24%; P = .001), and a family history of IBD was less common in Asia (3% vs 17%; P Conclusions We performed a large-scale population-based study and found that although the incidence of IBD varies throughout Asia, it is still lower than in the West. IBD can be as severe or more severe in Asia than in the West. The emergence of IBD in Asia will result in the need for specific health care resources, and offers a unique opportunity to study etiologic factors in developing nations.

Whether the results of randomized controlled trials on colorectal cancer (CRC) screening with guaiac fecal occult blood test (gFOBT) are transposable in the real world is questionable. gFOBT has several drawbacks, one is the requirement for frequent testing, which may limit compliance and thereby effectiveness. Aim: To assess the short term outcomes of the four first rounds of a population-based CRC screening program using gFOBT. Methods: Comparison of the outcomes of the four first rounds (R1 to R4) of the organized CRC screening program with Hemoccult II implemented in the Haut-Rhin, a French administrative area, since 2003 (Denis B et al Gut 2007;56:1579-84). All average-risk residents aged 50 74 were invited by mail to participate every other year. Results: Main outcomes are presented in the table. The crude uptake rate decreased from 47.9% to 38.5%. The decrease in adjusted uptake was similar in men and women but was observed in younger age groups (50 64) only and maximal in the 50 54 year age group. 15.8% of people who participated in Rn did not participate in Rn+1. Overall, 56.7% of the target population had completed at least one test and 19.6% four tests. More than 80% of the completed tests were provided by general practitioners. The positive predictive value for advanced neoplasia decreased significantly from 31.4% in R1 to 26.1% in R4 (and detection rate from 9.7‰ to 4.7‰). The rate of stage I colon cancers decreased significantly from 44.9% in R1 to 38.1% in R4. Conclusion: Participation and yield deteriorated with time in our organized population-based gFOBT CRC screening program. This deterioration was not observed in previous randomized controlled trials on gFOBT screening and may question the reproducibility of their effectiveness on the reduction of CRC mortality in the real world. Effort is needed to enhance uptake and to reduce inequalities in participation related to sex, age, place of residence and deprivation.

Objective: Ulcerative Colitis (UC) is rare in Asia but has seen a rise in prevalence over the past decade. Previous studies have suggested that UC is milder in Asians and fewer Asian patients require proctoproctocolectomy. The aim of the studywas to determine the proportion of Singaporean UC patients who required proctoproctocolectomy and the risk factors associated with the need for surgery in our cohort of patients. Methods: This is a retrospective study of 453 Asian UC patients seen at the Singapore General Hospital (SGH), Changi General Hospital (CGH) and National University of Singapore (NUH) from 1970 to 2011. Data was reviewed from case notes and electronic records. Cox proportional hazards model was used to identify univariate and multivariate risk factors for proctocolectomy. Results: There were 317 (70.0%) Chinese, 69 (15.2%) Indian, 45 (9.9%) Malay, and 22 (4.9%) patients of other Asian ethnicities in the study cohort. Male-to-female ratio was 1.5:1 (268:186). The majority of patients presented between the ages of 30 to 40 years old (28.5%), with no bimodal peak in age presentation. The mean duration from symptom onset to diagnosis was 22.9 months. At diagnosis, 116 (25.6%) patients presented with proctitis, 186 (42.6%) with left sided disease, and 139 (31.8%) with extensive colitis. 63 (13.9%) patients were steroid dependent. Azathioprine was eventually started in 61 (19.2%) Chinese, 19 (27.5%) Indian and 10 (22.2%) Malay patients, while proctocolectomy was required in 33 (10.4%) Chinese, 8 (10.1%) Indian and 4 (8.9%) Malay patients. The most common indications for proctocolectomy was medically refractory ulcerative colitis (64.4%) followed by acute severe colitis (15.6%) and cancer or dysplasia (13.3%). Risk factors associated with proctocolectomy were ESR more than 26 mm/h at diagnosis (p = 0.026), hemogoblin less than 12 g/dl at diagnosis (p = 0.015), steroid dependency (p< 0.0001), hospitalizations due to UC flares (p = 0.028) and extensive colitis (p = 0.037). Multivariate analysis showed that steroid dependency was the only variable independently associated with proctocolectomy (p = 0.001). Cumulative proctocolectomy rates were 3.0% at 1 year, 6.6% at 5 year, 9.2% at 10 year and 23.3% at 30 year. Age at diagnosis, gender, race and time to diagnosis did not affect surgical rates. Conclusion: About 10% of Asian UC patients in Singapore required proctocolectomy. While this is higher than the 3% of Koreans who required surgery for UC, it is lower than what has been reported in Caucasian cohorts. Steroid dependency was the only variable found to be associated with the need for proctocolectomy.

Abstract 3223 Abstract The human polyomavirus type 1, better known as “BK virus” (BKV), persists in a latent state in more than 90% of the world's population. It is infamous as a pathogen in kidney transplant recipients by causing BKV-associated nephropathy (BKVN) often resulting in allograft dysfunction and loss. BKV has also been associated with hemorrhagic cystitis (HC) in haematopoietic stem cell transplant (HSCT) recipients. However, treatment for this condition remains challenging, as the mechanism through which BKV reactivation causes HC in HSCT recipients is not known. In addition, there is currently little data about the reconstitution of BKV-specific immunity after HSCT and its relationship to HC. It is still unclear whether the BKV-specific T cell response helps to prevent and bring about the resolution of HC, or if HC is an immunopathology and the BKV specific immunity damages the bladder mucosa in the process of attacking BKV-infected urothelial cells. We hypothesized that BKV-associated HC is initiated by an imbalance between immune surveillance and BKV reactivation, followed by eventual rebound of BKV- specific T immunity causing an immunopathological reaction towards BKV-infected urothelial cells that ultimately lead to cystitis after HSCT. We aim to correlate BKV titre levels in the urine and blood with BKV- specific T cells. This is a novel prospective study that describes the immune reconstitution of BKV specific T cells immunity after allogeneic HSCT and uses the clinical manifestation of HC as a maker to analyze reconstitution of the immune system post HSCT. This study was approved by the institutional review board. Ten patients undergoing allogeneic HSCT were recruited over a 1 year period. The clinical data collected included conditioning regime, indication for transplant, presence of GVHD and development of HC. Patient's blood samples were collected prior to conditioning and at 4 weekly intervals for 24 weeks. Peripheral blood mononuclear cells (PBMCs) isolated from these whole blood samples were then stimulated with overlapping peptide mixes of BK LT and VP1. Quantification of BKV-specific T cells were accomplished by flow cytometry. Results revealed higher levels of CD3+IL-17+BKV specific T cells (p These preliminary results strongly suggest that BKV-associated HC is an immunopathology caused by IL-17 secreting BKV-specific T cells. Though our cohort of patients is small however in view of the promising results; we plan to extend the study to a larger cohort of patient. The demonstration of an immunological basis of HC will provide a theoretical framework for the development of potential immunotherapeutic interventions in the prevention and treatment of HC. Disclosures: No relevant conflicts of interest to declare.

results: There were a total of 104 respondents; 82.5% of respondents felt that GC is common in Singapore. While most risk factors (RF) were identified correctly, knowledge of dietary RF was deficient, with only 34.3% and 36.5% realising that a high salt diet and low vegetable/fruit intake were RF, respectively. 95.1% knew that GC can be asymptomatic, but if detected early, is potentially curable (97.1%). Majority of respondents felt that GC was best diagnosed by endoscopy and the best time to diagnose it was when asymptomatic. However, only 52% of the respondents felt that screening gastroscopy was worthwhile. For those willing to pay for screening gastroscopy, the mean cost they were willing to pay was S$243. conclusion: Our results show that while most RF of GC are well recognised, knowledge of dietary factors is deficient. There is ambivalence towards screening gastroscopy despite knowing that GC is common in Singapore and can be asymptomatic. This may be a barrier to tackling the problem of GC in Singapore. Before we recommend any GC screening programmes in the future, it may be important to optimise knowledge and change the mindsets of doctors in Singapore towards GC.