Exabis Library

Anal ulcerations are frequently observed in Crohn's disease (CD). Their natural history remains poorly known, especially in pediatric-onset CD. The aims of this study were: to determine in a population-based study the risk of anal ulcerations in pediatric onset CD; to identify risk factors for anal ulcerations; to evaluate the risk of progression towards suppurative lesions; to evaluate the risk factors of progression towards suppurative lesions.

All patients with a diagnosis of CD before the age of 17 years between 1988 and 2011 within the population-based registry EPIMAD were followed retrospectively until 2013. A specific collection of additional data was performed in patients with anal ulcerations at diagnosis or during follow-up. The variables collected included: proctological examination, diagnostic management (perineal MRI, endoscopic ultrasound, examination under general anaesthesia) and treatment (medical or surgical). Multivariate Cox models were used to identify factors associated with anal ulcerations and factors of progression towards suppurative lesions. An adjusted time-dependent Cox model was used to evaluate the risk of progression of anal ulcerations towards suppurative lesions.

1005 patients were included (females, 450 (44.8%); median age at diagnosis 14.4 years (IQR, 12.0-16.1)). 257 (25.6%) had anal ulceration at diagnosis. Cumulative incidence of anal ulceration at 5 and 10 years from diagnosis was 38.4% (CI95%, 35.2-41.4) and 44.0% (CI95%, 40.5-47.2).

The presence of extra-intestinal manifestations (HR 1.46, CI95% 1.19-1.80, p=0.0003) and upper digestive location (HR 1.51, CI95% 1.23-1.86, p<0.0001) at diagnosis were associated with the occurrence of anal ulceration. Conversely, ileal location at diagnosis was associated with a lower risk of anal ulceration (L2 vs L1 HR 1.51, CI95% 1.11-2.06, p=0.0087; L3 vs L1 HR 1.42, CI95% 1.08-1.85, p=0.0116). Among the 352 patients with at least one episode of anal ulceration, 82 (23.3%) developed perianal suppuration after a median follow-up of 5.7 years (IQR, 2.8-10.6). The risk of perianal suppuration was doubled in patients with anal ulceration compared to those who did not have any ulceration (HR 2.0, CI95% 1.45-2.74, p<0.0001).

In patients with anal ulceration, the diagnostic period (before or since the “biologic era”), exposure to immunosuppressants and/or anti-TNF did not influence the risk of perianal suppuration.

Anal ulceration is frequent in pediatric-onset CD, with nearly half of patients presenting with at least one episode after 10 years of evolution. Perianal suppurations are twice as frequent in patients with present or past anal ulceration. These results plead for a proactive therapeutic approach in case of anal ulcerations.

Ulcerative colitis and Crohn’s are both chronic inflammatory bowel diseases, associated with an increased risk of colitis-associated cancer secondary to the longstanding and severe intestinal inflammation. To reduce this risk patients are treated with drugs such as immunomodulators and biologicals. Studies however have shown that these therapies may be associated with an increased risk of extra-intestinal cancers as e.g. haematological malignancies, skin cancer, cervix cancer. Different types of drugs are associated with different types of cancer, e.g. patients treated with thiopurines are at risk of haematological malignancies, such as lymphomas, and non-melanoma skin cancer, whereas a relationship between melanoma and biologicals has been described. Therefore, the benefits and harms must be considered in treatment decision. To reduce the risks of malignancy it is advised temporarily interrupt treatment or restrict the use of certain drugs to a limited time. To avoid skin cancer sun protection and skin surveillance is recommended.

Many neoplastic complications are described in IBD these could be due to the desease or to the treatment. In this presentation we will focus on a case of multiple neuroendocrine tumors in a patient with Crhon's disease.
Educational objectives:
- to know the main neoplastic complications in IBD
- to understand the possible etiology.

1. To review the literature concerning neuroendocrine proliferations in IBD

2. To look at some examples of cases of neuroendocrine tumours

3. To discuss neuroendocrine micronests/microcarcinoids

To understand neuromuscular complications in IBD including secondary / medication induced changes and extraintestinal involvement of neuromuscular system.

In the last week of February 2020 hit Stockholm with increasing number of cases starting to appear at hospitals in the region. This prompted a rapid mobilisation of large scale biobanking and immediate immunological analysis at the Karolinska Institutet with the aim to understand COVID-19 disease pathogenesis. Fairly soon the Karolinska COVID-19 Immune Atlas was launched as an online resource providing scientists rapid access to biological data. In this talk, the research response to the pandemic will be discussed.

Educational objective:
To undertand the role human translational immunological research have in shedding light on disease mechanisms

1) Description of immune pathways that drive inflammation in IBD
2) Discussion of the pathways targeted by current and future therapies
3) review of clinical evidence supporting use of novel therapies (selective Jaki, Sphingosine modulators, anti p19 therapies)
4) Highlight the data on adverse effects of new therapies
5) Stem cell therapies for perianal fistulae
6) Discuss novel formulations of existing agents (low systemic bioavailable steroids)