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P639. Caesarean section is associated with a younger age at IBD diagnosis and a higher proportion of Crohn's disease vs. ulcerative colitis - data from the Swiss IBD Cohort Study

Background

The human intestinal microbiota has been identified as a crucial factor in the pathogenesis of IBD. Various studies revealed that delivery mode and lactation have a substantial impact on the initial composition of gut microbiota [1,2]. While initial bacterial communities are similar to the common skin flora in C-section babies, intestinal microbiota resembles the vaginal microbiota of their mothers after vaginal birth (VB) [1]. This impact of delivery mode can be detected for up to six months [3], potentially even notably longer. Data on the impact of delivery mode on future IBD is scant. One small study having looked at less than 100 IBD patients per group suggested a decreased risk of future IBD in subjects having undergone C-section [3]. We aimed to investigate whether delivery mode and breast feeding influences future IBD characteristics.

Methods

Using data from the Swiss IBD cohort study we compared the disease characteristics between patients having undergone C-section or VB as well as those having been breast-feed or not. Data on delivery mode and lactation were obtained through a short questionnaire given to all patients within the cohort.

Results

Among a total of 1139 IBD patients 6.3% were born by C-section, with a significantly higher portion in CD (7.7%) than in UC (4.8%) patients (p = 0.043). There was no difference in the age-matched C-section rate compared to the general rate in Switzerland. IBD patients born by C-section had a highly significant lower median age at diagnosis (23.0 vs. 29.3 years, p < 0.001; 22.0 vs. 27.0, p < 0.001 and 24.6 vs. 31.0 for CD and UC, respectively). Furthermore IBD patients born by C-section more often developed Erythema nodosum (p = 0.032) and more often received treatment with anti-TNF (p = 0.05).

Although patients born by C-section were breast-fed significantly less often compared to their counterparts born by VB (34.7 vs. 19.8%, p = 0.001) there were no significant differences regarding IBD phenotype or age at onset of disease between patient that were breastfed or not.

Table: Patient characteristics according to delivery mode
Vaginal birthC-sectionp-value
Number of patients, n, %1067 (93.7%)72 (6.3%)
Diagnosis, n (%)
Crohn's disease560 (52.5)47 (65.3)0.043
Ulcerative colitis480 (45.0)24 (33.3)
Indeterminate colitis27 (2.5)1 (1.4)
Age at diagnosis [years] (median, IQR; range)
All patients29.3, 22.3–39.2, 3.4–79.723.0, 18.8–29.0, 7.9–51.3<0.001
CD only27.0, 20.9–38.0, 4.6–78.422.0, 18.1–28.5, 8.0–51.3<0.001
UC only31.0, 23.9–40.5, 3.4–79.724.6, 21.2–29.9, 7.9–46.20.002
Disease location at inclusion, n (%)
Crohn's disease 0.112
 L1: ileal159 (28.4)13 (27.7)
 L2: colonic183 (32.7)12 (25.5)
 L3: ileocolonic191 (34.1)17 (36.2)
 L4: Upper GI only6 (1.1)3 (6.4)
 Unclear/unknown21 (3.8)2 (4.3)
Ulcerative colitis 0.436
 Pancolitis181 (37.7)8 (33.3)
 Left-sided colitis199 (41.5)12 (50.0)
 Proctitis92 (19.2)3 (12.5)
 Unclear/unknown8 (1.7)1 (4.2)
EIM history
Any EIM390 (36.6)27 (37.5)0.871
Arthritis281 (26.3)23 (31.9)0.298
Uveitis/Iritis48 (4.5)5 (6.9)0.377
Pyoderma gangrenosum14 (1.3)1 (1.4)1.000
Erythema nodosum55 (5.2)8 (11.1)0.032
Aphtous oral ulcers53 (5.0)3 (4.2)1.000
Sacroilitis41 (3.8)3 (4.2)0.754
Primary sclerosing cholangitis19 (1.8)1 (1.4)1.000
Other12 (1.1)0 (0.0)1.000
Surgery
Any surgery283 (26.5)21 (29.2)0.624
Intestinal surgery234 (21.9)15 (20.8)0.827
Fistula/abscess surgery136 (12.8)10 (13.9)0.779
Medication history
Oral 5ASA739 (69.3)46 (63.9)0.341
Topical 5ASA283 (26.5)16 (22.2)0.422
Antibiotics344 (32.2)23 (31.9)0.959
Immunomodulators (Aza/6MP)663 (62.1)49 (68.1)0.315
Methotrexate110 (10.3)8 (11.1)0.829
Anti-TNF alpha313 (29.3)29 (40.3)0.050
Systemic steroids718 (67.3)46 (63.9)0.552
Topical Steroids149 (14.0)8 (11.1)0.497
Budesonide240 (22.5)16 (22.2)0.958
Calcineurin inhibitors (Cyclo/Tacro)41 (3.8)2 (2.8)1.000
Breastfeeding
Yes, 6 months or more370 (34.7)18 (25.0)0.009
Yes, less than 6 months363 (34.0)18 (25.0)
No211 (19.8)25 (34.7)
Unknown123 (11.5)11 (15.3)

Conclusion

Delivery mode may have an impact on the future phenotype and course of disease in IBD patients independent from breastfeeding. Further studies on the reason underlying this association are warranted, including long-term prospective analyses of intestinal microbial composition from birth to adulthood between C-section and VB, especially in view of the world-wide increase in C-section rates.

1. Dominguez-Bello MG, Costello EK, Contreras M, et al., (2010), Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns., Proceedings of the National Academy of Sciences

2. Jost T, Lacroix C, Braegger CP, Chassard C., (2012), New Insights in Gut Microbiota Establishment in Healthy Breast Fed Neonates., PLoS ONE

3. Grönlund MM, Lehtonen OP, Eerola E, Kero P., (1999), Fecal microflora in healthy infants born by different methods of delivery: permanent changes in intestinal flora after cesarean delivery., J. Pediatr. Gastroenterol. Nutr

  • Written by:

    L. Biedermann1, N. Fournier2, C.N. Manser1, P. Frei1,3, J. Zeitz1, B. Misselwitz1, V. Pittet2, M. Fried1, C.P. Braegger4, S.R. Vavricka1,5, G. Rogler1, 1University Hospital Zurich, Gastroenterology & Hepatology, Zurich, Switzerland, 2University of Lausanne, IUMSP, Lausanne, Switzerland, 3Seespital Horgen, Gastroenterology & Hepatology, Horgen, Switzerland, 4University Children's Hospital Zurich, Division of Gastroenterology and Nutrition, Zurich, Switzerland, 5Hospital Triemli, Gastroenterology & Hepatology, Zurich, Switzerland