Crohn’s disease initiated with extraintestinal features

Crohn’s disease (CD) is a multifactorial, chronic immune-mediated disorder. The oral cavity is involved in 0.5% to 20% of the patients with CD. Oral manifestations of CD are sometimes nonspecific and can be overlooked by the clinicians. These manifestations may precede intestinal symptoms and can serve as indicators for early diagnosis. To increase awareness and to contribute to the standard intervention, here we report a paediatric case with persistent idiopathic swelling of the lower lip and perianal fistula. Microscopic examinations revealed multiple non-necrotising granulomas with chronic inflammation, oedema and lymphangiectasia. The patient was treated with metronidazole 500 mg and ciprofloxacin 500 mg twice a day for one month. The perioral lesions were managed with topical 0.03% tacrolimus and oral prednisone 10 mgtwice a day for one month, followed by a tapered regimen of 10 mg/day for another month. The patient’s symptoms improved without full remission at the 6-month follow-up.

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Predictors of Perianal Fistula Relapse in Crohn’s Disease

Inflammatory Bowel Diseases ◽

10.1093/ibd/izz200 ◽

2019 ◽

Vol 26 (6) ◽

pp. 926-931 ◽

Cited By ~ 1

Author(s):

Audrey Malian ◽

Pauline Rivière ◽

Dominique Bouchard ◽

François Pigot ◽

Marianne Eléouet-Kaplan ◽

...

Keyword(s):

Multivariate Analysis ◽

Crohn’S Disease ◽

Retrospective Study ◽

Crohn's Disease ◽

Odds Ratio ◽

Primary Outcome ◽

Perianal Fistula ◽

Pelvic Mri ◽

Relapse Rates

Abstract Background Despite an optimal medico-surgical management of perineal Crohn’s disease (PCD), fistula relapse still occurs in 30% of patients. Our aim was to determine predictors of fistula relapse in patients in remission after treatment of a PCD lesion. Methods Consecutive patients treated for fistulizing PCD have been included in a retrospective study when they achieved fistula remission within 3 months after the surgery. Remission was defined as the absence of any draining fistula at clinical examination. Primary outcome was the occurrence of a fistula relapse, defined as a subsequent perianal draining fistula or an abscess confirmed clinically and/or by pelvic MRI. Results One hundred and thirty-seven patients (57% female, median age: 35 years) corresponding to 157 abscess events, including 120 (76.4%) treated by anti-TNF after drainage, achieved fistula remission after surgery. During the follow-up period (median duration: 43 months [interquartile range 26 to 64]), 34 (22%) patients experienced a fistula relapse within a median time of 1.8 years. Survival without fistula was 96.7% at 1 year, 78.4% at 3 years, and 74.4% at 5 years. Fistula relapse rates were not different in patients receiving infliximab or adalimumab (P = 0.66). In patients treated by anti-TNF at inclusion, discontinuation of anti-TNF therapy (odds ratio 3.49, P = 0.04), colonic location (OR 6.25, P = 0.01), and stricturing phenotype (odds ratio 4.39, P = 0.01) were independently associated with fistula relapse in multivariate analysis. Conclusion In patients achieving fistula remission of PCD, relapse rates are low and are not different between infliximab and adalimumab. Discontinuation of anti-TNF therapy is associated with increased relapse rate.

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P240 CDEIS score of 2 is optimal cut-off associated with lower risk of disease progression in early Crohn’s disease: Data from the CALM study

Journal of Crohn s and Colitis ◽

10.1093/ecco-jcc/jjz203.369 ◽

2020 ◽

Vol 14 (Supplement_1) ◽

pp. S264-S266

Author(s):

R Ungaro ◽

R Jordan ◽

C Yzet ◽

P Bossuyt ◽

F Baert ◽

...

Keyword(s):

Crohn’S Disease ◽

Crohn's Disease ◽

Disease Progression ◽

Lower Risk ◽

Perianal Fistula ◽

Youden Index ◽

History Of ◽

Risk Of Disease ◽

Over Time

Abstract Background The optimal endoscopic target in early Crohn’s disease (CD) that limits long-term disease complications is unknown. Methods We analysed medical records from patients who had follow-up data since the end of CALM. Patients with Crohn’s disease endoscopic index of severity (CDEIS) scores at the end of CALM were included. The primary outcome was a composite of major adverse outcomes reflecting CD progression: new internal fistula/abscess, stricture, perianal fistula/abscess, CD hospitalisation, or CD surgery since the end of CALM. We compared median CDEIS and per cent improvement from baseline CDEIS. Youden index analysis was used to identify optimal CDEIS cut-off score associated with CD progression. Kaplan–Meier and Cox regression methods were used to compare rates of progression by different CDEIS targets. Multivariable models were adjusted for age, prior surgery, and stricturing behaviour. Results 110 patients with median age 28 (IQR 22–38) years, disease duration 0.2 (0.1–0.5) years, and median follow up of 3.1 (1.9–4.4) years were included. Eleven per cent had a history of stricture, 5.5% history of surgery, and 52% were originally in the tight control arm of the CALM study. Median CDEIS score at end of CALM was 3 (0–5.4) and 32 (29%) patients had disease progression. Baseline median CDEIS score was similar between those with and without progression [10.9 (7.5–15.5) vs. 11.9 (8–17.5)]. Median CDEIS score at the end of CALM was higher among those with progression [1.3 (0–5.1) vs. 4.9 (3–9.1), p < 0.001)]. Patients within higher quartiles of CDEIS score had higher rates of progression over time (Figure 1). Patients without disease progression had a greater median decrease in CDEIS score from baseline to end of CALM [90% (60–100%) vs. 50% (30–80%), p < 0.001]. The optimal CDEIS score cut-off was 2 with sensitivity 84%, specificity 60% and NPV 90% for progression. Patients with CDEIS ≤ 2 had less progression over time compared with patients with > 50% improvement from baseline CDEIS (not reaching CDEIS ≤ 2) and those not meeting either endpoint (Figure 2). On adjusted analysis, CDEIS score ≤ 2 was associated with a decreased risk of progression (aHR 0.23, 95% CI 0.09–0.56). Conclusion In early CD, a CDEIS score ≤ 2 is optimal cut-off associated with a lower risk of disease progression.

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P618 Treatment outcomes of patients with Crohn’s disease and complex perianal fistula in five European countries: the PREFACE retrospective study

Journal of Crohn s and Colitis ◽

10.1093/ecco-jcc/jjab076.739 ◽

2021 ◽

Vol 15 (Supplement_1) ◽

pp. S560-S560

Author(s):

M Ferrante ◽

L Siproudhis ◽

G Poggioli ◽

M Reinshagen ◽

S Milicevic ◽

...

Keyword(s):

Crohn’S Disease ◽

Crohn's Disease ◽

Treatment Outcomes ◽

Index Date ◽

Perianal Fistula ◽

European Countries ◽

Standards Of Care ◽

Patient Level ◽

Remission Rates

Abstract Background Presence of fistulas in Crohn’s disease (CD) is an indicator of poor prognosis; 20% of CD patients suffer from perianal fistula. There are few studies specifically designed to assess treatment outcomes in complex perianal fistula (CPF) in CD. This retrospective chart review study describes the outcomes of patients with CPF in CD in five European countries after medical and/or surgical treatment. Methods Adult patients with CD receiving treatment for a new episode of CPF during the eligibility period (September 2011 to September 2014), in Belgium, France, Germany, Italy and Spain, were included. Index date was defined as date of any medical or surgical CPF treatment initiation. Data was collected from CD diagnosis to at least 3 years after index date (except for deceased or lost to follow-up patients) to describe patient characteristics and treatments used for all CPF episodes since CD diagnosis. Effectiveness outcomes were measured as remission rates based on Fistula Drainage Assessment (FDA) recorded in medical charts for fistula reported at index date (index fistula). Remission rates are expressed as percentage rates on patient level after 6- and 12-months follow-up period. For calculation of treatment outcomes, the most recent FDA prior to the respective timepoint was used. Results A total of 372 patients (51% male) with a mean (SD) age of 38 (13) were included by 31 sites. Median time since CD diagnosis was 7 years, and median length of follow-up was 6 years. A total of 498 CPFs were presented at index date and during FU period. Out of the 498 CPFs, 94% were treated with at least one surgical intervention (most frequent: 61% long-term seton placement, 51% surgical drainage) and 82% with at least one medical treatment (most frequent: 40% anti-TNFs, 33% antibiotics, 16% immunosuppressants). After 6 months the remission rate at patient level for index fistula was 28% and after 12 months 35%. Conclusion Current standards of care achieved remission in one third of patients with CPF in CD over a period of one year. Improved therapeutic strategies and new treatment options are required to improve outcomes in this manifestation of CD.

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Aphthous stomatitis as the debut of Crohn’s disease

Experimental and Clinical Gastroenterology ◽

10.31146/1682-8658-ecg-169-9-97-100 ◽

2020 ◽

pp. 97-100

Author(s):

O. V. Gaus ◽

V. A. Akhmedov ◽

A. S. Korshunov

Keyword(s):

Crohn’S Disease ◽

Gastrointestinal Tract ◽

Crohn's Disease ◽

Granulomatous Inflammation ◽

Aphthous Stomatitis ◽

Systemic Complications ◽

Immune Mediated ◽

Transmural Inflammation ◽

Retromolar Region

Crohn’s disease is an immune-mediated disease characterized by non-specific granulomatous transmural inflammation with segmental damage to any part of the gastrointestinal tract with the formation of extraintestinal and systemic complications. Clinical observation of patient I., 23 years old, a student who was sent for consultation to a gastroenterologist in the direction of a dentist, is presented. Active examination of the gastrointestinal tract during the inspection did not show any complaints. He considers himself ill for 6 months, when he first complained of pain in the neck, sore throat, and body temperature rise to 37.4–37.5 °C, mostly in the evening. Were treated by an otolaryngologist and a dentist without significant effect. In this connection, a biopsy of the ulcerative defect of the left retromolar region was performed, revealing noncaseating granulomatous inflammation. A follow-up examination by a gastroenterologist with colonoscopy and biopsy made it possible to establish Crohn’s disease as the true cause of aphthous stomatitis.

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P334. Evolution of a long-term follow-up cohort of Crohn’s disease with complex perianal fistula: from antibiotic to combined AZA and anti-TNF based treatment ending up clinical and radiological healing with or without stoma

Journal of Crohn s and Colitis ◽

10.1093/ecco-jcc/jjw019.453 ◽

2016 ◽

Vol 10 (suppl 1) ◽

pp. S262.1-S262 ◽

Cited By ~ 1

Keyword(s):

Crohn’S Disease ◽

Crohn's Disease ◽

Perianal Fistula ◽

Long Term Follow Up ◽

Radiological Healing

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P238 Natural history of perianal fistulizing Crohn’s disease in the Swiss IBD cohort

Journal of Crohn s and Colitis ◽

10.1093/ecco-jcc/jjz203.367 ◽

2020 ◽

Vol 14 (Supplement_1) ◽

pp. S262-S262

Author(s):

N Aslan ◽

J B Rossel ◽

V Pittet ◽

E Safroneeva ◽

S Godat ◽

...

Keyword(s):

Cohort Study ◽

Crohn’S Disease ◽

Crohn's Disease ◽

Natural History ◽

Disease Duration ◽

Perianal Fistula ◽

Rectal Disease ◽

Perianal Fistulas ◽

History Of

Abstract Background Data of large cohort studies on the fate of perianal fistulizing Crohn’s disease (CD) is scarce. We aimed to evaluate the prevalence and natural history of perianal fistulas in adults with Crohn’s disease (CD). Methods Data from the Swiss IBD cohort study were analysed. The Swiss IBD Cohort study includes since 2006 IBD patients, follow-up questionnaires are completed once a year. Patients were recruited from university centres (80%), regional hospitals (19%), and private practices (1%). Results Among 2163 CD patients, 495 (22.9%) ever had perianal fistulas whereas 1668 (77.1%) did not. Patients with perianal fistulas were characterised by the following features when compared with patients without perianal fistulas: younger age at diagnosis (23.4 vs. 25.3 years, p = 0.001), longer disease duration at enrolment (9.6 vs. 4.9 years, p < 0.001), longer disease duration at latest follow-up (17.4 vs. 11.2 years, p < 0.001), less frequenty isolated ileal disease at diagnosis (15.8% vs. 28.6%, p < 0.001), more frequently rectal disease at enrolment (32.5% vs. 14.8%, p < 0.001) and latest follow-up (24.2% vs. 11.7%, p < 0.001), more frequently acne inversa (1.4% vs. 0.1%, p < 0.001), and more frequently intestinal resection (49.5% vs. 35.3%, p < 0.001). The prevalence of extraintestinal manifestations was not different (59.0% vs. 54.4%, p = 0.073). Compared with patients without perianal fistulas, patients with perianal fistulas were more frequently treated with topical 5-ASA (14.8% vs. 8.0%, p < 0.001), systemic steroids (78.2% vs. 70.1%, p < 0.001), azathioprine (82.6% vs. 77%, p = 0.008), methotrexate (28.3% vs. 22.2%, p = 0.005), infliximab (71.9% vs. 50.8%, p < 0.001), adalimumab (36% vs. 27.9%, p < 0.001), certolizumab pegol (18.6% vs. 11.5%, p < 0.001), and antibiotics (69.1% vs. 41.2%, p < 0.001). Regarding fistula anatomy, 321 patients (64.8%) had a low perianal fistula, 82 (16.6%) a high perianal fistula, and 227 (45.9%) a perineal fistula. The following fistula therapies were ever applied: perianal abscess drainage (45.7%), fistulectomy/fistulotomy (39.6%), seton drainage (28.7%), mucosal sliding flap (2%), fistula plug (1.4%), and fibrin glue instillation (1%). Conclusion In our national cohort roughly one-quarter of CD patients was diagnosed with perianal fistulizing disease. Compared with patients without perianal fistulas, patients with perianal fistulizing disease were characterised by several stigmata of complicated disease course such as a higher frequency of intestinal resections and higher prevalence of treatment with biologic agents.

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Recurrent Hepatocellular Carcinoma in Patient with Crohn’s Disease: Incidental or Expected Outcome of Azathioprine?

Case Reports in Gastrointestinal Medicine ◽

10.1155/2015/939136 ◽

2015 ◽

Vol 2015 ◽

pp. 1-4

Author(s):

Youssef Botros ◽

Mary Mathews ◽

Hiren Patel ◽

Nihar Shah ◽

Walid Baddoura ◽

...

Keyword(s):

Hepatocellular Carcinoma ◽

Crohn’S Disease ◽

Crohn's Disease ◽

Case Reports ◽

Disease Patient ◽

Aminosalicylic Acid ◽

Immune Mediated ◽

Increased Risk ◽

History Of

Hepatocellular carcinoma (HCC) usually occurs in patients with underlying risk factors such as liver cirrhosis and chronic hepatitis B. Although patients with Crohn’s disease (CD) are at an increased risk to develop malignancies such as colon cancer, the incidence of HCC in this population is extremely rare. We report a case of 62-year-old male with long history of CD treated with azathioprine (AZA) and aminosalicylic acid (ASA) who was incidentally diagnosed with HCC, for which left hepatectomy was done. Four years later during routine follow-up, patient had another hepatic lesion and underwent resection of the mass. The mechanism of occurrence of HCC in patient with CD is still controversial and may include immune mediated changes and medication related complications. AZA was reported in all case reports of CD that developed HCC. Through this report we hope to explore the complex pathophysiological mechanisms contributing to the development of HCC in the Crohn’s disease patient population.

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