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Background: Obesity is on the rise within the inflammatory bowel disease population. The impact obesity has on the natural history of Crohn's disease (CD) is not well-understood. We aimed to describe the prevalence of obesity in a population-based cohort of newly diagnosed patients with CD, and the impact obesity had on disease phenotype and outcomes of corticosteroid use, hospitalization, intestinal resection, and development of fistulizing or penetrating disease., Materials and Methods: A chart review was performed on Olmsted County, Minnesota residents diagnosed with CD between 1970 and 2010. Data were collected on demographics, body mass index, CD location and behavior, CD-related hospitalizations, corticosteroid use, and intestinal resection. The proportion of individuals considered obese at the time of CD diagnosis was evaluated over time, and CD-associated complications were assessed with Kaplan-Meier survival analysis., Results: We identified 334 individuals diagnosed with CD between 1970 and 2010, of whom 156 (46.7%) were either overweight (27.8%) or obese (18.9%) at the time of diagnosis. The proportion of patients considered obese at the time of their diagnosis of CD increased 2-3 fold over the course of the study period. However, obesity did not have a significant impact on the future risk of corticosteroid use, hospitalization, intestinal resection, or development of penetrating and stricturing complications., Conclusions: Obesity is on the rise in patients with CD, although in this cohort, there did not appear to be any negative association with future CD-related outcomes. Further prospective studies, ideally including obesity measures such as visceral adipose tissue assessment, are warranted to understand the implications of the rising prevalence of obesity on CD outcomes., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Alcohol-associated liver disease is increasing among females with an earlier onset and more severe disease at lower levels of exposure. However, there is paucity of literature regarding sex differences related to alcoholic hepatitis., Methods: Hospitalized patients with alcoholic hepatitis were selected from the US Nationwide readmissions database 2019. In this cohort, we evaluated sex differences in baseline comorbidities, alcoholic hepatitis related complications and mortality. A subset of patients with alcoholic hepatitis who were hospitalized between January and June 2019 were identified to study sex differences in 6 month readmission rate, mortality during readmission, and composite of mortality during index hospitalization or readmission., Results: Among 112 790 patients with alcoholic hepatitis, 33.3% were female. Female patients were younger [48 (38-57) vs. 49 (39-58) years; both P  < 0.001] but had higher rates of important medical and mental-health related comorbidities. Compared with males, females had higher rates of hepatic encephalopathy (11.5% vs. 10.1; P  < 0.001), ascites (27.9% vs. 22.5%; P  < 0.001), portal hypertension (18.5% vs. 16.4%; P  < 0.001), cirrhosis (37.3% vs. 31.9%; P  < 0.001), weight loss (19.0% vs. 14.5%; P  < 0.001), hepatorenal syndrome (4.4% vs. 3.8%; P  < 0.001), spontaneous bacterial peritonitis (1.9% vs. 1.7%; P  = 0.026), sepsis (11.1% vs. 9.5%; P  < 0.001), and blood transfusion (12.9% vs. 8.7%; P  < 0.001). Females had a similar in-hospital mortality rate (4.3%) compared to males (4.1%; P  = 0.202; adjusted odds ratio (OR) 1.02, 95% CI (cardiac index) 0.89-1.15; P  = 0.994). In the subset of patients ( N  = 58 688), females had a higher 6-month readmission rate (48.9% vs. 44.9%; adjusted OR 1.12 (1.06-1.18); P  < 0.001), mortality during readmission (4.4% vs. 3.2%; OR 1.23 (1.08-1.40); P  < 0.01), and composite of mortality during index hospitalization or readmission (8.7% vs. 7.2%; OR 1.15 (1.04-1.27); P  < 0.01)., Conclusion: Compared to their male counterparts, females with alcoholic hepatitis were generally younger but had higher rates of comorbidities, alcoholic hepatitis related complications, rehospitalizations and associated mortality. The greater risks of alcohol-associated liver dysfunction in females indicate the need for more aggressive management., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background & Aims: Guidelines recommend measuring antibody (Ab) titers to hepatitis B virus (HBV) after vaccination for patients with inflammatory bowel disease (IBD) or celiac disease (CD) ("patients with IBD/CD") and revaccinating when titers are low. Few data, however, support this recommendation. We aimed to compare effectiveness of HBV vaccination (immunity and infection rates) for patients with IBD/CD vs matched referents., Methods: Using the Rochester Epidemiology Project, we performed a retrospective cohort study of patients first diagnosed with IBD/CD (index date) while residing in Olmsted County, Minnesota, from January 1, 2000, through December 31, 2019. HBV screening results were obtained from health records., Results: In 1264 incident cases of IBD/CD, only 6 HBV infections were diagnosed before the index date. A total of 351 IBD/CD cases had documented receipt of 2 or more HBV vaccines before their index date and had hepatitis B surface antigen Ab (anti-HBs) titers measured after their index date. The proportion of patients with HBV-protective titers (≥10 mIU/mL) decreased with time before plateauing, with protective titer rates of 45% at 5 up to 10 years and 41% at 15 up to 20 years after the last HBV vaccination. The proportion of referents with protective titers also decreased with time and was consistently higher than the levels of patients with IBD/CD within 15 years after the last HBV vaccination. However, no new HBV infection developed in any of 1258 patients with IBD/CD during a median follow-up of 9.4 years (interquartile range, 5.0-14.1 years)., Conclusions: Routine testing of anti-HBs titers may not be indicated for fully vaccinated patients with IBD/CD. Additional studies are needed to confirm these findings in other settings and populations., (Copyright © 2023 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Avascular necrosis (AVN) is a known adverse event associated with corticosteroid (CS) usage. Inflammatory bowel disease (IBD) is often treated with a CS for induction of remission. We sought to describe clinical features and outcomes of IBD patients with AVN., Methods: In this retrospective, single-center, case-control study, patients with IBD who had a diagnosis of osteonecrosis, aseptic necrosis, or AVN from 1976 to 2009 were included, and each was matched with up to 2 controls (IBD but no AVN) on age, sex, IBD subtype, geographic area of residence, and date of IBD diagnosis. We abstracted risk factor data from the medical records. Conditional logistic regression was performed accounting for minor differences in age and date of first IBD visit to assess the relationship between putative risk factors and AVN, expressed as odds ratio and 95% confidence interval., Results: Eighty-five patients were diagnosed with IBD-AVN and were matched with 163 controls. The mean age at AVN diagnosis was 47.5 years. AVN was diagnosed a median of 12.2 years after IBD diagnosis, and the control group was followed for a median of 15 years after IBD diagnosis to ensure that they did not have AVN. Ten percent of patients with AVN did not have any CS exposure. History of arthropathy or estrogen use in Crohn's disease and use of CS, osteoporosis, and history of arthropathy in ulcerative colitis were significantly associated with AVN., Conclusions: Most patients with IBD-AVN had multifocal involvement. Most had received CS, but many patients had other risk factors including arthropathy., (© The Author(s) 2022. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Prior reports from small studies suggested an increased prevalence of respiratory diseases in patients with inflammatory bowel disease (IBD). Large population-based contemporary studies evaluating this association are lacking., Methods: In this retrospective observational cohort study utilizing the US Nationwide Readmissions Database year 2014, IBD patients ≥ 15 years of age were identified. Outcomes analyzed were the differences in the rates of diagnosed respiratory diseases between IBD and age- and sex-matched non-IBD control groups, and between patients with ulcerative colitis (UC) and Crohn disease (CD)., Results: The IBD study cohort and the matched non-IBD control group had 87,506 patients each (mean age, 52 years; 57% females). In patients with IBD, obstructive respiratory diseases were the most prevalent (asthma, 8.6%; and chronic obstructive pulmonary disease, 8.7%) followed by pleural diseases (1.9%). Compared with the non-IBD cohort, patients with IBD had a 46% higher rate of bronchiectasis, 52% higher rate of pulmonary vasculitis and interstitial pneumonia, 35% higher risk for lung nodules, 16% higher rate of pulmonary fibrosis, and a 5.5% higher rate of asthma. Among patients with IBD, patients with CD, compared with UC, had a 34% lower age/sex-adjusted risk for bronchiectasis, 56% lower risk for pulmonary vasculitis, 14% lower risk for pleural diseases, and approximately 30% higher risk for chronic obstructive pulmonary diseases., Conclusion: In this large population-based cohort study, patients with IBD had higher rates of certain respiratory diseases compared with the general population without IBD, and significant differences were present between CD and UC., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Menopause, defined by the complete cessation of menstrual cycles for 12 consecutive months, may occur at a younger age in women who have concomitant immune dysregulation. Our aim was to determine whether women with inflammatory bowel disease (IBD) experience an earlier onset of menopause compared to women without IBD., Methods: This was a retrospective cohort study using resources of the Rochester Epidemiology Project, a collaboration between clinics, hospitals, and medical facilities in Olmsted County, Minnesota. From these people, women who were diagnosed with IBD between 1970 and 2010 comprised the case cohort while the reference cohort included women with no diagnosis of IBD. Data including age, body mass index (BMI), ethnicity, smoking status, age at onset of menopause, and current use of hormone therapy were collected. Patients with history of hysterectomy or oophorectomy were excluded. Wilcoxon rank-sum test for numeric variables and Fisher's exact test for categorical variables were used to analyze the data., Results: A total of 171 women met criteria for inclusion (83 cases and 88 controls). Mean age of menopause in women with IBD was 50.0 years compared to 51.5 years in women with no IBD ( P = .006). There was no difference in BMI of women with and without IBD (28.7 versus 28.2 kg m -2 ; P = .9), respectively. There were more former smokers (33.7%) and current (6%) smokers in the IBD group ( P = .009) compared to the non-IBD group., Conclusions: IBD is associated with an earlier onset of menopause. Although it is unclear if this mean difference of 1.5 years is clinically relevant, it is known that early menopause is associated with an increased risk of osteoporosis and cardiovascular disease. Further research on the possible mechanisms is needed., (© The Author(s) 2022. Published by Oxford University Press on behalf of Crohn's & Colitis Foundation.)

Background & Aims: Epidemiologic studies from Europe and North America have reported an increasing incidence of microscopic colitis (MC) in the late 20th century, followed by a plateau. This population-based study assessed recent incidence trends and the overall prevalence of MC over the past decade., Methods: Residents of Olmsted County, MN, diagnosed with collagenous colitis (CC) or lymphocytic colitis (LC) between January 1, 2011, and December 31, 2019 were identified using the Rochester Epidemiology Project. Clinical variables were abstracted by chart review. Incidence rates were age- and sex-adjusted to the 2010 US population. Associations between incidence and age, sex, and calendar periods were evaluated using Poisson regression analyses., Results: A total of 268 incident cases of MC were identified with a median age at diagnosis of 64 years (range, 19-90 y); 207 (77%) were women. The age- and sex-adjusted incidence of MC was 25.8 (95% CI, 22.7-28.9) cases per 100,000 person-years. The incidence of LC was 15.8 (95% CI, 13.4-18.2) and CC was 9.9 (95% CI, 8.1-11.9) per 100,000 person-years. A higher MC incidence was associated with increasing age and female sex (P < .01). There was no significant trend in age- and sex-adjusted incidence rate over the study period (P = .92). On December 31, 2019, the prevalence of MC, LC, and CC (including cases diagnosed before 2011) was 246.2, 146.1, and 100.1 per 100,000 persons, respectively., Conclusions: The incidence of MC and its subtypes was stable between 2011 and 2019, but its prevalence was higher than in previous periods. The incidence of MC continues to be associated with increasing age and female sex., (Copyright © 2022 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background and Aims: There remains a historical misconception that inflammatory bowel disease [IBD] patients are underweight. However, recent data suggest rates of obesity in IBD parallel to those of the general population. The impact obesity has on the natural history of IBD is unclear. We aimed to determine obesity rates at the time of IBD diagnosis in a population-based cohort of ulcerative colitis [UC] patients., Methods: Chart review was performed on patients diagnosed with UC over 1970-2010. Data were collected on demographics, body mass index [BMI], disease characteristics, IBD-specific hospitalisations, intestinal resection, and corticosteroid use. The proportion of patients who were obese at the time of their diagnosis was evaluated over time, and survival free of IBD-related complications was assessed using Kaplan-Meier survival analysis., Results: A total of 417 adults were diagnosed with UC over 1970-2010, 55.4% of whom were classified as either overweight [34.8%] or obese [20.6%]. The prevalence of obesity increased 2-3-fold over the 40-year study period. Obese patients had a 72% increased risk of hospitalisation (hazard ratio [HR],1.72; 95% confidence interval [CI], 1.10-2.71; p = 0.018) when compared with normal weight patients. Additionally, with each incremental increase in BMI by 1 kg/m2, the risk of hospitalisation increased by 5% [HR,1.05; 95% CI, 1.01-1.08; p = 0.008] and risk of corticosteroid use increased by 2.6% [HR,1.026; 95% CI, 1.00-1.05; p = 0.05]., Conclusions: The prevalence of obesity in the UC population is increasing and may have negative prognostic implications, specifically regarding risk of future hospitalisation and corticosteroid use. Additional prospective studies are necessary to more clearly define these associations., (© The Author(s) 2021. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Introduction: Vulvar involvement is a rare complication of Crohn's disease (CD). The optimal treatment of vulvar CD is unknown., Methods: We conducted a 25-year retrospective cohort study of vulvar CD from 3 referral centers. Clinical features and outcomes were studied., Results: Fifty patients were identified. The most common vulvar symptoms were pain (74%), edema (60%), ulcerations (46%), nodules (36%), and abscess (34%). Medical management leading to symptomatic improvement varied, and 5 patients ultimately required surgery., Discussion: Vulvar CD manifests with a broad spectrum of symptoms. Aggressive medical management was frequently effective, although surgery was required in 10% of cases., (Copyright © 2021 by The American College of Gastroenterology.)

Background: Inflammatory bowel disease (IBD) is associated with an increased acute coronary syndrome (ACS) risk. Data are limited regarding the epidemiology and outcomes of ACS in patients with IBD., Methods: A retrospective cohort analysis of patients with IBD admitted for ACS in the U.S. Healthcare Cost and Utilization Project National Inpatient Sample for 2005 to 2015 was conducted. We analyzed trends in IBD-ACS admissions and mortality, differences in risk profiles, management strategies, and in-hospital mortality between IBD-ACS and non-IBD ACS and between ulcerative colitis (UC) and Crohn disease (CD)., Results: We studied 6,872,415 non-IBD ACS and 24,220 IBD-ACS hospitalizations (53% with CD). During the study period, the number of hospitalizations for IBD-ACS increased, particularly those related to CD. Compared with non-IBD ACS, patients with IBD-ACS had a lower prevalence of cardiovascular risk factors and similar rates of coronary angiography and revascularization. The in-hospital mortality rate was lower with IBD-ACS (3.9%) compared with non-IBD ACS (5.3%; odds ratio, 0.81; 95% confidence interval, 0.69-0.96; P = 0.011) and was stable between 2005 and 2015. Risk factors, ACS management strategies, and mortality were similar between CD and UC. Coagulopathy, weight loss, and gastrointestinal bleeding were more frequent in IBD-ACS and were strong independent predictors of mortality., Conclusions: Hospitalizations for ACS in patients with IBD increased in recent years but death rates were stable. The ACS-related risk profiles and mortality were modestly favorable with IBD-ACS than with non-IBD ACS and were similar between CD and UC. Complications more frequently associated with IBD were strongly associated with mortality. These findings indicate that aggressive management of IBD and ACS comorbidities is required to improve outcomes., (© 2020 Crohn’s & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Certolizumab pegol (CZP) has been successfully used for the treatment of Crohn disease (CD); however, real-world data regarding the utility of CZP trough levels (CTLs) are lacking. We aimed to correlate CTL with CD outcomes and to determine frequency of CZP antibodies., Methods: Retrospective evaluation of all CD patients on maintenance CZP with CTL obtained between 2016 and 2019. Outcomes included: median CTL, presence of anti-CZP antibodies, biochemical response (BR), clinical response (CR), radiologic response (RR), radiologic healing (RH), and mucosal healing (MH)., Results: Seventy-seven CD patients were included. Median CTL was 18.9 µg/mL (interquartile range, 7.6-35.4). Twenty-three patients (27.3%) had positive antibody levels, with lower median CTL compared to patients with no antibodies (0.0 vs 29.8; P < 0.0001). Median CTL levels were higher in patients with vs without CR (30.4 vs 10.3 µg/mL; P = 0.0015) and RR (29.6 vs 5.8 µg/mL; P = 0.006). CZP dosing at least every 2 weeks was associated with higher odds of achieving MH (odds ratio, 3.2; 95% confidence interval, 1.03-9.97). CTL resulted in change in clinical management in 62.7% of cases and presence of CMZ antibodies was associated with an odds ratio of 5.83 (95% confidence interval, 1.57-21.73) of change in management. Receiver operating characteristic curve and quartile analysis suggested that CTL >19 µg/mL is associated with increased rates of CR and RR., Conclusions: Higher CTL was significantly associated with CR and RR. The rate of CZP antibodies was 27.3%. Our data suggest maintenance CTL of ≥19 µg/mL should be achieved in order to optimize outcomes in clinical practice., (© The Author(s) 2021. Published by Oxford University Press on behalf of Crohn's & Colitis Foundation.)

Background: We sought to compare the dysplasia detection rate of high-definition white light endoscopy (HDWLE) with that of chromoendoscopy in patients with long-standing inflammatory bowel disease (IBD)., Methods: This is a retrospective observational cohort of patients with IBD who underwent surveillance colonoscopy between October 1, 2016 and September 30, 2017. We assessed the association between dysplasia detection and multiple variables., Results: A total of 808 unique colonoscopies were performed, of which 150 (18.6%) included chromoendoscopy. Primary sclerosing cholangitis was a comorbid diagnosis in 24.5% of patients. The performing endoscopist was an IBD specialist with 37.1% of patients and had >10 years' experience with 64.9% of patients. Prior dysplasia had been seen in 245 (30.3%) patients: 102 (68.0%) and 143 (22.0%) among patients who had chromoendoscopy and HDWLE, respectively. Dysplasia in polyps was found in 129 procedures (15.1%). Among patients who had chromoendoscopy and HDWLE, polypoid dysplasia was identified in 50 (33.0%) and 79 (12.0%) patients, respectively, P < 0.01. Dysplasia in random biopsies was found in 39 patients (4.8%): 15 (10%) who had chromoendoscopy and 24 (3.6%) who had HDWLE (P < 0.001). On multivariate analysis, patient and disease characteristics significantly associated with an increased odds for polypoid dysplasia included older age at diagnosis (odds ratio [OR] = 1.3 per 10 years; 95% confidence interval [CI], 1.07-1.60), having an IBD physician endoscopist (OR = 1.6; 95% CI, 1.01-2.67), having an endoscopist with less than 10 years' experience (OR = 1.8; 95% CI (1.16-2.89), and prior random dysplasia (OR = 4.2; 95% CI (1.93-9.17). Concomitant primary sclerosing cholangitis was significantly associated with random dysplasia (OR = 2.3; 95% CI, 1.02-5.07). After multivariate analysis adjusting for these variables, chromoendoscopy was no more likely to identify dysplasia than was HDWLE., Conclusions: Chromoendoscopy and HDWLE had a similar diagnostic yield for dysplasia detection in patients with chronic IBD-colitis after adjusting for multiple known risk factors., (© 2020 Crohn’s & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The global incidence of inflammatory bowel disease (IBD) has increased considerably during the past few decades. 1 IBDs, composed of Crohn's disease (CD) and ulcerative colitis (UC), are characterized by heterogeneous presentation and widely variable clinical course. The therapeutic goals are to induce and maintain remission. Despite the current treatments available, many patients do not achieve this goal., (Copyright © 2021 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: We sought to estimate the incidence of home parenteral nutrition (HPN) use in a population-based cohort of patients with Crohn disease (CD), and to assess clinical outcomes and complications associated with HPN., Methods: We used the Rochester Epidemiology Project (REP) to identify residents of Olmsted County, who were diagnosed with CD between 1970 and 2011, and required HPN., Results: Fourteen out of 429 patients (3.3%) with CD received HPN (86% female). Eleven patients (79%) had moderate-severe CD and 12 patients (86%) had fistulizing disease. Thirteen patients (93%) underwent surgery, primarily due to obstruction. Among CD incidence cases, the cumulative incidence of HPN from the date of CD diagnosis was 0% at 1 year, 0.5% at 5 years, 0.8% at 10 years, and 2.4% at 20 years. Indications for HPN included short bowel syndrome in 64%, malnutrition in 29%, and bowel rest in 21%. The median duration of HPN was 2.5 years. There was an average weight gain of 1.2 kg at 6 months, an average weight loss of 1.4 kg at 1 year, and a further weight loss of 2.2 kg at 2 years from the start of HPN. Patients were hospitalized a mean of 5 times after the start of HPN, mainly due to catheter-related bloodstream infections and thrombosis., Conclusions: Less than 4% of patients with CD need HPN. Most have moderate to severe disease with short bowel syndrome or malnutrition. Possible reasons for the patients' weight loss could be noncompliance, and increased metabolic needs because of active disease., (© The Author(s) 2020. Published by Oxford University Press on behalf of Crohn's & Colitis Foundation.)

Background and Aims: Patient-reported outcomes (PROs) will become increasingly important as primary endpoints in future clinical trials. We aimed to evaluate the relationship between health-related quality of life (HRQoL) and the combination of patient-reported clinical symptoms (ClinPRO2) and Mayo endoscopic subscore (MES) in patients with ulcerative colitis (UC)., Methods: We conducted a prospective cross-sectional study of 90 consecutive UC patients who were scheduled for sigmoidoscopy or colonoscopy. All patients completed the following questionnaires: (1) self-rated rectal bleeding and stool frequency (ClinPRO2); (2) Short Inflammatory Bowel Disease Questionnaire (SIBDQ); (3) European Quality of Life 5-Dimensions 3-Level (EQ5D3L); (4) Work Productivity and Activity Impairment questionnaire (WPAI); (5) Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F); and (6) Hospital Anxiety and Depression Scale (HADS). The endoscopic images were graded according to the MES. "No symptoms" was defined as a symptom score of 0, and "mucosal healing" was defined as MES score of 0-1. Correlations between the combined ClinPRO2 and MES with HRQoL were assessed using Spearman's correlation coefficients., Results: The combination of the ClinPRO2 and MES was well correlated to SIBDQ ( r = -0.70), EQ5D3L ( r = -0.51), WPAI ( r = 0.62), FACIT-F ( r = -0.58), and HADS-depression ( r = 0.45). SIBDQ scores had strong correlations with FACIT-F ( r = 0.86), WPAI ( r = -0.80), and HADS-depression ( r = -0.75) ( p < 0.05 for all correlations). Patients with no symptoms reported the greatest all HRQoL scores., Conclusions: In patients with ulcerative colitis, the combination of a ClinPRO2 and the MES had good correlation with the SIBDQ. In addition, SIBDQ was well correlated to the various HRQoL.

Background: This study sought to re-estimate the cumulative incidence of perianal or rectovaginal fistulas and the associated proctectomy rate in the prebiologic era vs the biologic era using a population-based cohort of Crohn's disease (CD) patients., Methods: The medical records of 414 residents of Olmsted County, Minnesota, who were diagnosed with CD between 1970 and 2010 were reviewed. The cumulative incidence of perianal or rectovaginal fistulas from time of CD diagnosis and the cumulative rate of proctectomy from date of first perianal or rectovaginal fistula diagnosis were estimated using the Kaplan-Meier method., Results: Eighty-five patients (20.5%) diagnosed with CD between 1970 and 2010 had at least 1 perianal or rectovaginal fistula episode between January 1, 1970, and June 30, 2016. The cumulative incidence of perianal or rectovaginal fistulas was 18% after 10 years, 23% after 20 years, and 24% after 30-40 years from CD diagnosis. The cumulative incidence of perianal or rectovaginal fistulas was significantly lower in patients diagnosed in 1998 or after than in patients diagnosed before 1998 (P = 0.03, log-rank). Among 85 patients developing perianal or rectovaginal fistulas, 16 patients (18.8%) underwent proctectomy for the treatment of perianal or rectovaginal fistulas during follow-up., Conclusions: In a population-based inception cohort of CD, one-fifth of patients were diagnosed with at least 1 perianal or rectovaginal fistula. The cumulative probability of perianal or rectovaginal fistulizing disease has decreased over time., (© 2018 Crohn’s & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background/aims: The clinical utility of vedolizumab (VDZ) trough levels (VTLs) in inflammatory bowel disease (IBD) is not well defined. The aims of this study are to determine the median VTLs and frequency of detected antibodies, the correlation of VTLs with C-reactive protein (CRP) and mucosal healing (MH), and the change in clinical management based on VTLs., Methods: A cross-sectional study of IBD patients treated with VDZ with VTLs checked between July 1, 2016, and March 1, 2017, was conducted. Mucosal healing was defined as absence of mucosal ulcers in Crohn's disease (CD) and Mayo endoscopic score ≤1 for ulcerative colitis (UC). Normal CRP was defined as ≤8 mg/L., Results: A total of 171 patients (62% CD, 31% UC, 7% indeterminate colitis) were included. Median VTLs was 15.3 ug/mL (range, 0-60), and 1 patient had detectable antibodies to VDZ. Patients with a normal CRP had a median VTLs of 17.3 ug/mL vs 10.7 ug/mL in high CRP patients (P = 0.046). This was noted in CD (20.3 vs 10.4 ug/mL; P = 0.005) but not in UC patients (14.4 vs 20.8; P = 0.72). Mucosal healing was achieved in 35% of patients (37 of 105); among these, median VTLs was 13.7 ug/mL vs 16.1 ug/mL in patients who did not achieve MH (P = 0.64). Vedolizumab trough levels resulted in a change in clinical management in 73%., Conclusions: Our cohort showed a low rate of immunogenicity to VDZ and an association between VTLs and CRP in CD but not in UC patients. No relationship between VTLs and MH was detected. Vedolizumab trough level measurements altered management in approximately three fourths of patients., (© 2018 Crohn’s & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Although inflammatory bowel disease (IBD) has been more predominant in white populations, an increasing incidence of IBD in nonwhites has been reported. We sought to evaluate the incidence rates and temporal trends of IBD by race and ethnicity., Methods: The resources of the Rochester Epidemiologic Project were used to identify 814 county residents newly diagnosed with IBD from 1970 through 2010. Race was categorized into whites and nonwhites. Ethnicity was categorized into Hispanic and non-Hispanic. Incidence rates were estimated and adjusted for age and sex to the 2010 United States (US) population. Trends in incidence rates were evaluated by Poisson regression., Results: The adjusted annual incidence rate of IBD for whites was 21.6 cases per 100,000 person-years [95% confidence interval (CI), 20.0-23.1] and for nonwhites it was 13 per 100,000 (95% CI, 8.3-17.5). The incidence rates for whites and nonwhites increased by 39% and 134%, respectively, from 1970 through 2010. The adjusted annual incidence rate of IBD for Hispanics was 15 cases per 100,000 person-years (95% CI, 6.3-23.6) and for non-Hispanics was 20 per 100,000 (95% CI, 18.5-21.6). The incidence rate for Hispanics decreased by 56%, while the rate for non-Hispanics increased by 33%, from 1985 through 2010. In a Poisson regression, white race ( p < 0.0001), a later year of diagnosis ( p < 0.001), male sex ( p < 0.001) and younger age ( p = 0.009) were significantly associated with a higher incidence rate of IBD., Conclusions: There were significant racial and ethnic differences in the incidence and temporal trends of IBD over the last four decades in this US population-based cohort., Competing Interests: Conflict of interest statement: The authors declare that there is no conflict of interest.

Most patients with ulcerative colitis (UC) have mild-to-moderate disease activity, with low risk of colectomy, and are managed by primary care physicians or gastroenterologists. Optimal management of these patients decreases the risk of relapse and proximal disease extension, and may prevent disease progression, complications, and need for immunosuppressive therapy. With several medications (eg, sulfasalazine, diazo-bonded 5-aminosalicylates [ASA], mesalamines, and corticosteroids, including budesonide) and complex dosing formulations, regimens, and routes, to treat a disease with variable anatomic extent, there is considerable practice variability in the management of patients with mild-moderate UC. Hence, the American Gastroenterological Association prioritized clinical guidelines on this topic. To inform clinical guidelines, this technical review was developed in accordance with the Grading of Recommendations Assessment, Development and Evaluation framework for interventional studies. Focused questions included the following: (1) comparative effectiveness and tolerability of different oral 5-ASA therapies (sulfalsalazine vs diazo-bonded 5-ASAs vs mesalamine; low- (<2 g) vs standard (2-3 g/d) vs high-dose (>3 g/d) mesalamine); (2) comparison of different dosing regimens (once-daily vs multiple times per day dosing) and routes (oral vs rectal vs both oral and rectal); (3) role of oral budesonide in patients mild-moderate UC; (4) comparative effectiveness and tolerability of rectal 5-ASA and corticosteroid formulations in patients with distal colitis; and (5) role of alternative therapies like probiotics, curcumin, and fecal microbiota transplantation in the management of mild-moderate UC., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: There are conflicting data as to whether inflammatory bowel diseases (IBDs) increase risk for cardiovascular disease. We sought to examine the risk of acute myocardial infarction (AMI) and heart failure in patients with IBD., Methods: We identified patients diagnosed with IBD in Olmsted County, Minnesota, from 1980 through 2010 (n = 736). For each patient, 2 individuals without IBD (controls, n = 1472) were randomly selected, matched for age, sex, and index date of disease diagnosis. Primary outcomes were AMI and heart failure. Cox proportional hazards analysis was used to estimate the risk of AMI and heart failure., Results: After adjustments for traditional cardiovascular disease risk factors, IBD associated independently with increased risk of AMI (adjusted hazard ratio [aHR], 2.82; 95% CI, 1.98-4.04) and heart failure (aHR, 2.03; 95% CI, 1.36-3.03). The relative risk of AMI was significantly increased in patients with Crohn's disease (aHR vs controls, 2.89; 95% CI, 1.65-5.13) or ulcerative colitis (aHR vs controls, 2.70; 1.69-4.35). The relative risk of AMI was increased among users of systemic corticosteroids (aHR vs controls, 5.08; 95% CI, 3.00-8.81) and nonusers (aHR vs controls, 1.79; 95% CI, 1.08-2.98). The relative risk of heart failure was significantly increased among patients with ulcerative colitis (aHR, 2.06; 95% CI, 1.18-3.65), but not Crohn's disease. The relative risk of heart failure was increased among users of systemic corticosteroids (aHR, 2.51; 95% CI, 1.93-4.57), but not nonusers., Conclusions: In a population-based cohort study, we found that despite a lower prevalence of traditional risk factors for AMI and heart failure, patients with IBD are at increased risk for these cardiovascular disorders., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the mortality of Crohn disease (CD) and ulcerative colitis (UC) and temporal trends in mortality., Patients and Methods: All 895 residents of Olmsted County, Minnesota, first diagnosed as having inflammatory bowel disease (IBD) (411 with CD and 484 with UC) from January 1, 1970, through December 31, 2010, were followed through June 30, 2016. Standardized mortality ratios (SMRs) were computed-expected rates were derived from the US 2010 background population. To determine overall and cause-specific mortality, each patient with IBD was matched with 5 county residents, and Cox regression analysis was used to assess time to death., Results: A total of 895 patients with IBD and 4475 patients without IBD were included. Seventy-four patients with CD died compared with 59.2 expected (SMR, 1.25; 95% CI, 0.98-1.57), and 77 patients with UC died compared with 108.1 expected (SMR, 0.71; 95% CI, 0.56-0.89). In CD, the risk of dying was significantly associated with diagnosis from 1970 through 1979 (SMR, 1.90; 95% CI, 1.24-2.78). Of those diagnosed after 1980, the risk of dying in patients with CD was similar to the US background population. In UC, the risk of dying was less than expected in all periods of diagnosis. In the Cox regression analysis, overall mortality was not significantly higher in CD (hazard ratio [HR], 1.26; 95% CI, 0.97-1.63) or UC (HR, 0.89; 95% CI, 0.70-1.14) compared with the comparison cohort. The risk of dying of digestive diseases (HR, 3.70; 95% CI, 1.24-11.0) and respiratory diseases (HR, 2.72; 95% CI, 1.36-5.44) was increased in CD but not UC., Conclusion: In this cohort, overall mortality in patients with CD diagnosed after 1980 did not differ from that in the US background population. Overall mortality in patients with UC diagnosed from 1970 through 2010 was lower than the expected mortality., (Copyright © 2018 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: Ileocolonoscopy and computed tomography (CT) or magnetic resonance (MR) enterography (CTE/MRE) are utilized to evaluate patients with small bowel (SB) Crohn's disease (CD). The purpose of our study was to estimate the impact of capsule endoscopy (CE) on patient management after clinical assessment, ileocolonoscopy, and CTE/MRE., Methods: We prospectively analyzed 50 adult CD patients without strictures at clinically indicated ileocolonoscopy and CTE/MRE exams. Providers completed pre- and post-CE clinical management questionnaires. Pre-CE questionnaire assessed likelihood of active SBCD and management plan using a 5-point level of confidence (LOC) scales. Post-CE questionnaire assessed alteration in management plans and contribution of CE findings to these changes. A change of ≥2 on LOC scale was considered clinically meaningful., Results: Of the 50 patients evaluated (60% females), median age was 38 years, median disease duration was 3 years, and median Crohn's Disease Activity Index (CDAI) score was 238 points. All CTE/MRE studies were negative for proximal disease. CE detected proximal disease in 14 patients (28%) with a median Lewis score of 215 points. CE findings altered management in 17 cases (34%). The most frequent provider-perceived benefits of CE were addition of new medication (29%) and exclusion of active SB mucosal disease (24%)., Conclusion: CE is a safe imaging modality that alters clinical management in patients with established SBCD by adding incremental information not available at ileocolonoscopy and cross-sectional enterography.

Objective: Microscopic colitis (MC) is a common cause of chronic diarrhoea, often with additional symptoms. No validated instruments exist to assess disease activity in MC, making it difficult to compare efficacy of treatments between clinical trials. We aimed to identify clinical features that independently predicted disease severity and create a Microscopic Colitis Disease Activity Index (MCDAI)., Design: Patients with MC were prospectively administered a survey assessing their GI symptoms and the IBD Questionnaire (IBDQ). A single investigator also scored a physician global assessment (PGA) of disease severity on a 10-point scale. Multiple linear regression identified which symptoms best predicted the PGA. These symptoms were then combined in a weighted formula to create the MCDAI. The relationship between MCDAI and the IBDQ was investigated., Results: Of the 175 patients enrolled, 13 (7.4%) did not complete the survey. The remaining 162 had a median age of 66 years (range, 57-73) and 74% were female. Several clinical features were independently associated with PGA (number of unformed stools daily, presence of nocturnal stools, abdominal pain, weight loss, faecal urgency and faecal incontinence). These parameters were combined to create the MCDAI, which strongly predicted the PGA (R 2 =0.80). A 1-unit decrease in disease activity (ΔMCDAI) was associated with a 9-unit increase in quality of life (ΔIBDQ)., Conclusions: The MCDAI strongly predicted the PGA and correlated with a validated measure of quality of life. Several symptoms in addition to diarrhoea are associated with disease severity in MC., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background and Aims: Several studies have suggested significant associations between environmental factors and the risk of developing inflammatory bowel disease [IBD]. However, data supporting the role of antibiotics are conflicting. The aim of this study was to evaluate the association between antibiotic use and new-onset IBD., Methods: We conducted a population-based case-control study using the Rochester Epidemiology Project of Olmsted County, Minnesota. We identified 736 county residents diagnosed with IBD between 1980 and 2010 who were matched to 1472 controls, based on age, sex and date of IBD diagnosis. Data on antibiotic use between 3 months and 5 years before IBD diagnosis were collected. Logistic regression models were used to estimate associations between antibiotic use and IBD, and were expressed as adjusted odds ratio [AOR] with 95% confidence interval [CI]., Results: Antibiotic use occurred in 455 IBD cases [61.8%] and 495 controls [33.6%] [p < 0.001]. In multivariate analysis, there were statistically significant associations between antibiotic use and new-onset IBD [AOR, 2.93; 95% CI, 2.40-3.58], Crohn's disease [CD] [AOR, 3.01; 2.27-4.00] and ulcerative colitis [UC] [AOR, 2.94; 95% CI, 2.23-3.88]. A cumulative duration of antibiotic use ≥ 30 days had the strongest AOR [6.01; 95% CI, 4.34-8.45]. AOR for those receiving antibiotics under the age of 18 years was 4.27 [95% CI, 2.39-7.91], 2.97 for age 18-60 years [2.36-3.75] and 2.72 for age > 60 years [1.60-4.67]., Conclusions: This population-based case-control study suggests a strong association between antibiotic use and the risk of both new-onset CD and new-onset UC. The risk was increased among all age-onset IBD., (Copyright © 2017 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com)

Rationale: Microscopic colitis is a common cause of diarrhea. Pentoxifylline, a xanthine derivative with anti-tumor necrosis factor-alpha properties, is prescribed for intermittent claudication and other disorders. Our goal was to evaluate the outcomes of patients with microscopic colitis treated with pentoxifylline., Patient Concerns: Nine patients with microscopic colitis (8 collagenous colitis and 1 lymphocytic colitis) seen at Mayo Clinic, Rochester, between January 1, 1997 and November 30, 2016, were included. The median age was 56.9 years (range 51.6-60.2), 8 were female (89%), and the median disease duration was 64.8 months (range 60-109). The indications for treatment were budesonide refractoriness in 7 patients, budesonide dependence in 1 patient, and budesonide intolerance in 1 patient., Diagnoses: A histological diagnosis of microscopic colitis was confirmed in all patients., Interventions: Pentoxifylline 400 mg three times a day was used for a median of 3 months (range 2.5-8.3)., Outcomes: Complete response occurred in 1 patient (11%) and partial response in 3 patients (33%). The patient who achieved complete response was treated with pentoxifylline due to budesonide intolerance, and completed 43 months of successful maintenance therapy. There were no adverse effects reported., Lessons: The majority of budesonide-experienced patients with active microscopic colitis did not respond to pentoxifylline. However, it was well-tolerated, with 1 patient achieving long-term remission and one-third of the cohort having a partial response. Larger controlled studies are required to evaluate the efficacy of pentoxifylline and predictors of response in microscopic colitis. In particular, patients who are not budesonide-refractory may be more likely to respond.

Background: Microscopic colitis (MC) is a common cause of chronic diarrhoea. Various treatment options have been described, but there are limited data describing outcomes of corticosteroid-sparing treatments., Aim: To evaluate the outcomes of patients with active MC treated with immune modulators., Methods: All patients seen at Mayo Clinic, Rochester between January 1, 1997 and November 30, 2016 with a histological diagnosis of MC were identified. Patients treated with an immune modulator of interest were selected and clinical outcomes recorded., Results: Seventy-three MC patients (50 collagenous colitis and 23 lymphocytic colitis) with a median disease duration of 24 months (range, 7-60) were included. The indications for treatment were budesonide-refractoriness in 66%, budesonide dependence in 29%, and budesonide intolerance in 5%. Median age was 51.8 years (range, 43.4-63.1) and 61 (84%) were female. Thiopurines were used in 49 patients (67%) for a median of 4 months (range, 1.5-15). Complete and partial response occurred in 43% and 22% respectively. Adverse effects resulting in therapy cessation occurred in 17 patients (35%). Twelve patients (16%) were treated with methotrexate for a median of 14 months (3-18.8). Complete and partial response occurred in 58% and 17%, respectively. Anti-TNF therapy was used in 10 patients (14%) for a median of 4 months (range, 2.3-5.5). Complete response occurred in four patients and partial response in four patients., Conclusions: The majority of patients with active MC responded to thiopurines, methotrexate, or anti-TNF therapy. Larger controlled studies are required to confirm the efficacy and safety of these medications in MC., (© 2017 John Wiley & Sons Ltd.)

Background & Aims: The incidence and prevalence of inflammatory bowel diseases (IBD) continue to increase worldwide. We sought to update incidence rates of Crohn's disease (CD) and ulcerative colitis (UC) in a well-defined United States population, calculating values for Olmsted County, Minnesota through 2010. We also calculated prevalence values., Methods: The resources of the Rochester Epidemiology Project were used to identify county residents who were diagnosed with IBD (CD or UC), based on previously set criteria. Those with new diagnoses of CD or UC between 1970 and 2010 were identified as incidence cases, and those meeting diagnostic criteria on January 1, 2011, were identified as prevalence cases. Incidence rates were estimated (adjusted for age and sex to the US white population in 2010). Trends in incidence based on age at diagnosis, sex, and year of diagnosis were evaluated by Poisson regression., Results: The incidence cohort included 410 patients with CD (51% female) and 483 individuals with UC (56% male). Median age of diagnosis was 29.5 years for persons with CD (range, 4-93 years) and 34.9 years for UC (range, 1-91 years). From 2000 through 2010, the adjusted annual incidence rate for CD was 10.7 cases per 100,000 person-years (95% confidence interval [CI], 9.1-12.3 person-years) and for UC was 12.2 per 100,000 (95% CI, 10.5-14.0 person-years). On January 1, 2011, there were 380 residents with CD, with an adjusted prevalence of 246.7 cases per 100,000 persons (95% CI, 221.7-271.8 cases per 100,000 persons), and 435 residents with UC, with an adjusted prevalence of 286.3 (95% CI, 259.1-313.5 cases per 100,000 persons). Male sex was significantly associated with a higher incidence rate of UC, and younger age was significantly associated with a higher incidence rate of CD., Conclusions: Estimated incidence rates for UC and CD in Olmsted County are among the highest in the United States. Extrapolating the adjusted prevalence to the most recent US Census, there could be approximately 1.6 million persons in the United States with IBD., (Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Use of immunosuppressants and inflammatory bowel disease (IBD) may increase the risk of pneumonia caused by Pneumocystis jirovecii (PJP). We assessed the risk of PJP in a population-based cohort of patients with IBD treated with corticosteroids, immune-suppressive medications, and biologics., Methods: We performed a population-based cohort study of residents of Olmsted County, Minnesota, diagnosed with Crohn's disease (n = 427) or ulcerative colitis (n = 510) from 1970 through 2011. Records of patients were reviewed to identify all episodes of immunosuppressive therapies and concomitant PJP prophylaxis through February 2016. We reviewed charts to identify cases of PJP, cross-referenced with the Rochester Epidemiology Project database (using diagnostic codes for PJP) and the Mayo Clinic and Olmsted Medical Center databases. The primary outcome was risk of PJP associated with the use of corticosteroids, immune-suppressive medications, and biologics by patients with IBD., Results: Our analysis included 937 patients and 6066 patient-years of follow-up evaluation (median, 14.8 y per patient). Medications used included corticosteroids (520 patients; 55.5%; 555.4 patient-years of exposure), immunosuppressants (304 patients; 32.4%; 1555.7 patient-years of exposure), and biologics (193 patients; 20.5%; 670 patient-years of exposure). Double therapy (corticosteroids and either immunosuppressants and biologics) was used by 236 patients (25.2%), with 173 patient-years of exposure. Triple therapy (corticosteroids, immunosuppressants, and biologics) was used by 70 patients (7.5%) with 18.9 patient-years of exposure. There were 3 cases of PJP, conferring a risk of 0.2 (95% CI, 0.01-1.0) to corticosteroids, 0.1 (95% CI, 0.02-0.5) cases per 100 patient-years of exposure to immunosuppressants, 0.3 (95% CI, 0.04-1.1) cases per 100 patient-years of exposure to biologics, 0.6 (95% CI, 0.01-3.2) cases per 100 patient-years of exposure to double therapy, and 0 (95% CI, 0.0-19.5) cases per 100 patient-years of exposure to triple therapy. Primary prophylaxis for PJP was prescribed to 37 patients, for a total of 24.9 patient-years of exposure., Conclusions: In a population-based cohort of patients with IBD treated with corticosteroids, immunosuppressants, and biologics, there were only 3 cases of PJP, despite the uncommon use of PJP prophylaxis. Routine administration of PJP prophylaxis in these patients may not be warranted, although it should be considered for high-risk groups, such as patients receiving triple therapy., (Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Little is known about the cumulative extent of bowel resection among patients with Crohn's disease., Methods: Using the resources of the Rochester Epidemiology Project, we identified a cohort of 310 incident cases of Crohn's disease from Olmsted County, Minnesota who were diagnosed between 1970 and 2004. Operative and pathology reports were reviewed for bowel resection length. Median bowel resection lengths (with interquartile range [IQR]) were calculated per resection, cumulatively, and as a rate per year of follow-up., Results: One hundred forty-seven patients underwent 1 or more bowel resections. The median follow-up time per patient was 13.6 years (range, 0.2-39 years). Among the 141 patients with resection data available, 211 resections were performed (100 patients with 1 resection, 24 with 2 resections, 9 with 3 resections, 6 with 4 resections, 1 with 5 resections, and 1 patient with 7 resections). The median length of bowel resected was 40 cm (IQR, 22-65 cm) at any resection. The median cumulative length of bowel resected was 64 cm (38-93 cm) during the follow-up period. The median (IQR) rate of bowel resected was 4.2 cm total bowel annually (2.8-7.7 cm). The median length resected was highest for the first resection (52 cm; IQR, 32-71 cm). A mixed regression analysis showed that the length of the first resection was significantly greater than that of the second (P = .002), without significant differences between the second and third or subsequent resections., Conclusions: In a population-based cohort of patients with Crohn's disease, the median cumulative length of total bowel resected was 64 cm during the follow-up period; the median rate of bowel loss due to resection was 4.2 cm annually., Competing Interests: No conflicts for Peyrin-Biroulet, Harmsen, Tremaine, or Zinsmeister., (Copyright © 2016 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Chromoendoscopy (CE) identifies dysplastic lesions with a higher sensitivity than white-light endoscopy (WLE). The role of CE in the management of dysplasia on surveillance WLE in inflammatory bowel disease (IBD) remains unclear., Methods: A retrospective cohort of IBD patients with colorectal dysplasia on WLE who subsequently underwent CE between January 1, 2006 and August 31, 2013 was identified. Endoscopic and histologic findings were compared among the index WLE, first CE, and subsequent CE. Outcomes assessed included endoscopic lesion removal, surgery or repeat CE, and diagnosis of colorectal cancer., Results: Ninety-five index cases were identified. The median duration of IBD was 18 years (interquartile range 9.3-29.8); 78 patients had ulcerative colitis. Dysplasia was identified in 55 patients during the index WLE with targeted biopsies of 72 lesions. The first CE visualized dysplastic lesions in 50 patients, including 34 new lesions (not visualized on the index examination). Endoscopic resection was performed successfully of 43 lesions, most in the cecum/ascending colon (n = 20) with sessile morphology (n = 33). After the first CE, 14 patients underwent surgery that revealed 2 cases of colorectal cancer and 3 cases of high-grade dysplasia. Multiple CEs were performed in 44 patients. Of these, 20 patients had 34 visualized lesions, 26 of which were new findings., Conclusion: Initial and subsequent CE performed in IBD patients with a history of colorectal dysplasia on WLE frequently identified new lesions, most of which were amenable to endoscopic treatment. These data support the use of serial CEs in this high-risk population., (Copyright © 2016 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Patients with inflammatory bowel disease (IBD) may be at higher risk for hidradenitis suppurativa (HS). We studied the risk and clinical characteristics of HS in a population-based cohort of patients with IBD., Methods: We identified all cases of HS (confirmed by biopsy and/or dermatologic evaluation) in a population-based inception cohort of Olmsted County, Minnesota, residents diagnosed with IBD between 1970 and 2004 and followed up through August 2013. We estimated the incidence rate ratio of HS in patients with IBD compared with the general population, and described the clinical characteristics, risk factors, and management of HS., Results: In 679 IBD patients followed up over a median of 19.8 years, we identified 8 patients with HS (mean age, 44.4 ± 8.3 y; 7 women; 6 obese). Compared with the general population, the incidence rate ratio of HS in IBD was 8.9 (95% confidence interval, 3.6-17.5). The 10- and 30-year cumulative incidence of HS was 0.85% and 1.55%, respectively. Five patients had Crohn's disease, 4 of whom had perianal disease; of 3 patients with ulcerative colitis, 2 had undergone ileal pouch-anal anastomosis. Axillae, groin, and thighs were the most common sites of involvement. Six patients had Hurley stage 2 disease (recurrent abscesses with sinus tracts and scarring, involving widely separated areas), and required a combination of antibiotics and surgery; none of the patients were treated with anti-tumor necrosis factor-α agents., Conclusions: In this population-based study, patients with IBD were approximately 9 times more likely to develop HS than the general population, with a female predisposition., (Copyright © 2016 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Certolizumab pegol (CZP) is Food and Drug Administration (FDA)-approved to treat Crohn's disease (CD). However, the efficacy and safety of CZP outside clinical trials are not well established., Aim: To report the efficacy, safety and predictors of response to CZP in CD patients treated during a 6-year period since FDA-approval at a tertiary care centre., Methods: All CD patients who received CZP at our institution between 2008 and 2013 were evaluated through retrospective medical record-based review of steroid-free complete response (SCR), loss of response and safety., Results: A total of 358 patients were included. One hundred twelve patients (31.3%) and 189 (52.8%) received CZP as their second and third biological agent, respectively. The probability of SCR at 26 week was 19.9% (95% CI, 15.9-24.5). The probability of survival free of loss of response at 2 year was 45.7% (95% CI, 32.5-59.5). A predictor of SCR was age at CD diagnosis of >40 years old (hazard ratio, HR relative to those <17, 4.69; 95% CI, 1.75-12.61). Negative predictors included present perianal fistula (HR, 0.39; 95% CI, 0.16-0.98) and prior primary nonresponse to adalimumab (ADA; HR relative to secondary loss of response, 0.18; 95% CI, 0.04-0.76). Twenty-three patients (6.4%) experienced serious adverse events and 19 patients (5.3%) discontinued CZP due to adverse events., Conclusions: Certolizumab pegol was both effective and well tolerated for the treatment of Crohn's disease in this large tertiary care centre enriched with biologics-exposed patients. It may be more effective in patients without early-aged Crohn's disease diagnosis, prior primary nonresponse to adalimumab and present perianal fistula., (© 2015 John Wiley & Sons Ltd.)

Objectives: To estimate the overall risk of cancer in a population-based cohort of patients with inflammatory bowel disease (IBD) and how IBD-related medications modify this risk., Methods: We identified all incident cancers (excluding nonmelanoma skin cancer) after IBD diagnosis in a cohort of 839 patients diagnosed as having IBD from January 1, 1940, through December 31, 2004, in Olmsted County, Minnesota, and followed up for a median 18 years through December 31, 2011 (122 patients taking biologic agents at last follow-up). We calculated standardized incidence ratios (SIRs) with 95% CIs of all cancers and compared cancer risk in patients treated with immunomodulators (IMMs) and biologics with that of patients not exposed to these medications, using an incidence rate ratio (IRR)., Results: One hundred nine patients developed 135 cancers. The 10-year cumulative probability of cancer was 3.8%. Patients with Crohn disease (SIR, 1.6; 95% CI, 1.2-2.1) but not ulcerative colitis (SIR, 1.1; 95% CI, 0.8-1.4) had an increased overall risk of cancer compared with the general population. Patients treated with IMMs (relative to IMM-naive patients) had an increased risk of melanoma (IRR, 5.3; 95% CI, 1.1-24.8) (and a numerically higher risk of hematologic malignant tumors [IRR, 4.2; 95% CI, 0.9-19.2]), although this risk returned to baseline on discontinuation of IMM treatment. Patients treated with biologics (relative to biologic-naive patients) had a numerically higher risk of hematologic malignant tumors (IRR, 5.3; 95% CI, 0.7-40.5). There was no significant increase in the risk of gastrointestinal malignancies in patients with IBD compared with the general population., Conclusions: We observed an increased risk of melanoma in IMM-treated patients with IBD, and this risk returned to baseline after discontinued use of the medications., (Copyright © 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)