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Langholz E.,Gastroenterology Section
Therapeutic Advances in Gastroenterology

The description of the prognosis of inflammatory bowel disease (IBD) is based on systematic follow-up of population-based cohorts. A steady increase in incidence of IBD has occurred. The distribution of ulcerative colitis (UC) is fairly uniform with a preponderance of left-sided disease. One-third of Crohns disease (CD) patients present with colonic disease, one-third with ileocolonic disease and one-third with small bowel disease. IBD is associated with extra-intestinal manifestations (EIMs) in up to 36% of patients. Uveitis and episcleritis are the most common. The cumulative probability of a relapsing course in UC is 90% after 25 years. In CD disease behaviour varies substantially with time. At diagnosis behaviour is inflammatory in 70% of patients. At follow-up there is a change to either stricturing or penetrating disease. Most patients with CD will eventually require surgery. Risk factors for CD recurrence after surgery include penetrating/fistulizing disease behaviour, young age, short duration of disease before first surgery and ileocolonic disease. The incidence of colorectal cancer (CRC) in UC seems to be decreasing. The risk of CRC in CD seems to be equivalent to the risk in UC. Patients with small bowel CD are also at increased risk of small bowel adenocarcinoma. CD is associated with a mortality rate 20-70% higher than expected, whereas mortality in UC is equivalent to that of the general population. The improved prognosis of IBD, especially UC, could be due to a chemopreventive effect of the medications used. Further studies are needed to develop the best strategy for the reduction of mortality and cancer risk in IBD. Source

Beste L.A.,General Internal Medicine | Beste L.A.,Health Services Research and Development | Beste L.A.,University of Washington | Ioannou G.N.,Gastroenterology Section | And 8 more authors.
Clinical Gastroenterology and Hepatology

Background & Aims: Surveillance of patients with cirrhosis for hepatocellular carcinoma (HCC) with liver ultrasound every 6 months has been linked to longer survival and greater use of definitive treatment. However, less than 20% of patients typically undergo routine surveillance. Methods: We conducted a quasi-experimental study to assess whether a primary care-oriented, point-of-care clinical reminder improves HCC surveillance. Our study included patients with cirrhosis who made 1 or more primary care visits to 8 Veterans Affairs (VA) facilities over 18 months. Clinicians at 1 facility were sent a reminder to perform liver ultrasound assessments for patients with cirrhosis who had not received surveillance in the preceding 6 months. Outcomes included the proportion ofpatients receiving adequate HCC surveillance (defined as >2 instances of liver imaging >6 monthsapart) and HCC diagnosis and stage. Because it was a quality improvement project, this study did not require approval by an institutional review board under Federal law and VA policy. Results: Baseline rates of adequate HCC surveillance were similar at all facilities (18.2% at the intervention site vs 16.1% elsewhere; P= 23). After the reminder was implemented, adequate surveillance at the intervention site (for 790 patients) increased by 51%, but was unchanged at the other facilities (for 2094 patients) (27.6% vs 17.5%; P < .001). Adequate surveillance occurred more often at the intervention site (adjusted odds ratio, 1.29; 95% confidence interval, 1.03-1.61; P= .02). A higher crude percentage of patients was diagnosed with HCC at the intervention site than elsewhere (3.2% vs 1.9%; P= .03). We detected no difference in tumor stage at diagnosis. Conclusions: In a VA population, a clinical reminder system increased HCC surveillance in patients with cirrhosis. © 2015 AGA Institute. Source

Morgan T.R.,Gastroenterology Section | Morgan T.R.,University of California at Irvine
Recent Results in Cancer Research

Hepatitis C virus (HCV) infection causes chronic hepatitis, which can progress to cirrhosis and hepatocellular carcinoma (HCC). The incidence of hepatocellular carcinoma in the United States tripled between 1975 and 2005, and is expected to increase further, and to remain elevated for more than 20 years. Curing hepatitis C infection in patients with cirrhosis through treatment with peginterferon and ribavirin reduces the risk of developing hepatocellular carcinoma. Several noncurative treatments also appear to reduce the risk of hepatocellular carcinoma in patients with chronic hepatitis C. Prospective studies report a reduced incidence of hepatocellular carcinoma among patients treated with a mixture of carotenoids with or without myo-inositol, with vitamin K 2, or with polyprenoic acid (an acyclic retinoid). Uncontrolled and/or retrospective studies have reported beneficial effects of treatment with Sho-saiko-to, glycyrrhizin and ursodeoxycholic acid on hepatocellular carcinoma incidence. Meta-analyses of epidemiologic studies show a reduced risk of hepatocellular carcinoma among liver disease patients who drink two or more cups of coffee per day. Numerous agents prevent or reduce hepatocarcinogenesis in animal models. An ongoing Phase II clinical trial is evaluating S-adenosylmethionine (SAMe) as a potential chemopreventive agent in hepatitis C cirrhosis. Overall, these data suggest that chemoprevention of hepatocellular carcinoma in patients with chronic hepatitis C is an achievable objective. © 2010 Springer Berlin Heidelberg. Source

Afif W.,Mayo Medical School | Afif W.,McGill University | Sandborn W.J.,Mayo Medical School | Sandborn W.J.,University of California at San Diego | And 5 more authors.
Inflammatory Bowel Diseases

Background: Subgroups of patients with inflammatory bowel disease (IBD) may have an increased risk of developing lymphoma. We sought to identify factors that were associated with lymphoma in patients with IBD. Methods: Cases and controls were identified through a centralized diagnostic index. We identified 80 adult patients with IBD who developed lymphoma between 1980 and 2009. For each case, 2 controls were matched for subtype of IBD, geographic location, and length of follow-up. Conditional logistical regression was used to assess associations between risk factors and the development of lymphoma. Results: Sixty patients were males (75%) versus 77 controls (48%). Median age at index date was 59 years for cases and 42 years for controls. Twenty patients (25%) and 23 controls (14%) were receiving immunosuppressive medications at the index date. Four patients (5%) and 6 controls (4%) were receiving anti-tumor necrosis factor α agents at the index date. In multiple variable analysis, age per decade (odds ratio, 1.83;95% confidence interval, 1.37-2.43), male gender (odds ratio, 4.05;95% confidence interval, 1.82-9.02) and immunosuppressive exposure at the index date (odds ratio, 4.20;95% confidence interval, 1.35-13.11) were significantly associated with increased odds of developing lymphoma. Disease severity and use of anti-tumor necrosis factor α agents were not independently associated with developing lymphoma. When testing was performed on patients exposed to immunosuppressive or anti-tumor necrosis factor α medications, Epstein-Barr virus was identified 75% of the time. Conclusions: In this case-control study, increasing age, male gender, and use of immunosuppressive medications were associated with an increased risk of lymphoma in patients with IBD. Copyright © 2013 Crohn's and Colitis Foundation of America, Inc. Source

Collins B.S.,University of Southern California | Lin H.C.,Gastroenterology Section | Lin H.C.,University of New Mexico
Digestive Diseases and Sciences

Background: Chronic abdominal pain (CAP) in children, a condition that accounts for approximately 25% of pediatric gastroenterology office visits, may be a precursor to irritable bowel syndrome in adults. Recently, small intestinal bacterial overgrowth (SIBO) has been reported in 78-84% of IBS patients regardless of their abdominal symptoms, compared to 20% in healthy controls. Aims: The aim of this study was, therefore, to assess the prevalence of SIBO in children with CAP. Methods: Seventy-five children aged 8-18 years diagnosed with CAP based on the Rome II criteria and 40 healthy controls were enrolled. All subjects underwent a lactulose breath hydrogen test (LBT) to assess for SIBO. Children with CAP also filled out symptom questionnaires. Results: There was a 91% prevalence of an abnormal LBT suggestive of SIBO in the children with CAP and 35% in controls (odds ratio = 16.7, 95% confidence interval 6.0-57.5, P < 0.0001). A comparison of CAP children with a positive LBT to CAP children with a negative LBT revealed the former had significantly more "urgency to have a bowel movement" (P = 0.049) and experienced less "soiling" (P = 0.016) than those with a negative LBT. No significant differences were found between the two groups in terms of the location of their pain or any other associated symptoms. Conclusions: Similar to adults with IBS, there is a significantly higher prevalence of SIBO in children with CAP. Randomized controlled studies are needed to determine if eradication of SIBO will lead to symptom improvement in these patients. © 2009 Springer Science+Business Media, LLC. Source

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