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P161. Presence of stenosing and penetrating lesions at MRI but not deep ulcers at endoscopy predicts surgery requirements in CD in the era of biologics

A. Jauregui-Amezaga1, J. Rimola2, I. Ordás1, S. Rodríguez2, A. Ramírez-Morros1, M. Gallego1, S. Pinó Donnay1, M.C. Masamunt1, B. González1, E. Ricart1, J. Panés1, 1Hospital Clínic de Barcelona, Gastroenterology Department, Barcelona, Spain, 2Hospital Clínic de Barcelona, Radiology Department, Barcelona, Spain

Background

Severe endoscopic lesions (SELs) in colonic Crohn's disease (CD) patients have been related with higher risk of colectomy and penetrating complications. The aim of our study was to re-assess the influence of SELs on surgery requirements in CD patients and compare it with the predictive capacity of magnetic resonance imaging (MRI). The influence of treatment on disease course was also determined.

Methods

CD patients from a single reference center undergoing simultaneous evaluation with endoscopy and MRI in the context of two prospective studies (2006–2011) were included. Baseline assessment of clinical activity, biomarkers, colonoscopy (CDEIS Score, diagnosis of SELs and MELs) and MRI (ulcers, stenosis and fistulae diagnosis, MaRIA Score) was performed. Patients were followed up until surgery or the end of follow-up. SELs were defined as deep ulcerations covering >10% of mucosal area of at least one segment of ileum-colon and MELs as any endoscopic lesions not defined as SELs.

Results

From 116 patients included, 109 were followed up after initial evaluation. CD location was ileal (29%), colonic (32%) and ileocolonic (39%). Ulcers (severe or superficial) were present in 83% patients at baseline colonoscopy (SELs in 44%), stenosis in 35% and pseudopolyps in 17%. At baseline MRI, ulcers were identified in 70% patients, stenosis in 25% and fistulae in 17%. During follow up (median 50 months), 72% patients received anti-TNF drugs and 29 patients (27%) underwent surgery, 23/29 within the first 2 years after inclusion. Indication for surgery was stenosis in 13 cases (45%), fistulizing complication in 7 (24%), perforation in 3 (10%), inflammatory activity in 3 (10%), dysplasia in 1 (3%) and others in 2 (7%). Risk of surgery was higher in Montreal A1 (diagnosed before 16 years, p =  0.02), Montreal B2 and B3 (stenosing and fistulizing behavior, p < 0.001), in patients with perianal disease (p0.02) and in those with longer CD duration (p =  0.006). Surgery requirements were not related with the presence of deep ulcers at baseline endoscopy (23% SELs vs 30% no SELs) or MRI (29% ulcers vs 21% no ulcers), but detection of stenosis or fistulae at MRI was associated with higher risk of surgery (p = 0.001). In multivariate analysis, perianal disease (OR = 5.7, p = 0.02) and detection of fistulae in MRI (OR = 10.5, p = 0.003) were associated with higher risk of surgery, whereas anti-TNF treatment during follow up slightly decreased the risk of surgery (OR = 0.9, p =  0.002).

Conclusion

Presence of fistulae at MRI or perianal disease is associated with an increased risk of surgery in CD patients, whereas anti-TNF treatment slightly reduces this risk. Under current therapeutic strategies, presence of ulcers at baseline colonoscopy or MRI is not a predictor of surgery in CD.