Introduction

Crohn’s disease (CD) is a chronic inflammatory bowel disease that may result in progressive bowel damage and complications requiring surgery. Despite an increasing number of available advanced targeted therapies, the literature reveals conflicting results concerning the prevalence of surgeries in CD.

Aims & Methods

The aim of the study was to examine the number of intestinal and perianal fistula surgeries in patients with CD in Austria from 2011 through 2019. We conducted a retrospective analysis of real-world data on surgery in CD patients of the Austrian health insurance funds (covering 98% of the Austrian population) from 2011 through 2019. Data before 2011 were unavailable, and the years after 2019 were excluded due to a potential influence caused by the coronavirus pandemic. All patients with a recorded CD-specific intestinal (bowel resection and/or stricturoplasty) or perianal fistula surgery and an ICD-10 diagnosis of CD(K50.x) during the observation period were included. We calculated the absolute number of operations per year, the prevalence per 100,000 persons of the Austrian population (the prevalence of CD in Austria is unknown) and the change in the operation rate per year.

Results

During the observation period, 4,812 intestinal and 4,802 perianal fistula operations were performed. We observed an increase of +8.8% and +58.9%, respectively, in bowel and perianal fistula operations from 2011 through 2019, see Table. If the numbers were adjusted for the increase of the Austrian population, the number of bowel operations remained stable (+1.9%), however, the number of perianal fistula operations still increased significantly (+48.8%).

Year	Austrian population	Intestinal operations	Perianal fistula operations	Prevalence of intestinal operations/ 100,000	Prevalence of perianal fistula operations/ 100,000
2011	8,388,534	503	423	6.00	5.04
2012	8,426,311	555	481	6.59	5.71
2013	8,477,230	539	491	6.36	5.79
2014	8,543,932	491	514	5.75	6.02
2015	8,629,519	537	509	6.22	5.90
2016	8,739,806	505	487	5.78	5.57
2017	8,795,073	538	586	6.12	6.66
2018	8,837,707	597	639	6.76	7.23
2019	8,951,520	547	672	6.11	7.51

Conclusion

Despite novel therapies, the number of patients requiring intestinal surgery for CD remained stable while the number of perianal fistula operations increased. A potential increase in the prevalence of CD in Austria, as described in other European countries, might reveal a decrease in the rate of intestinal surgeries.

Clinical Case Summary

Cryptosporidiosis is a gastrointestinal infection caused by the protozoan Cryptosporidium spp. It is typically self-limited in immunocompetent patients. However, in immunocompromised individuals, it can lead to moderate to severe diarrhea and significant morbidity and mortality.¹
We present the case of a 31-year-old woman with a history of Crohn’s disease in remission, who presented with a one-week history of diarrhea (up to 10 bowel movements daily), abdominal pain, and fever (38°C). Laboratory tests revealed an elevated C-reactive protein (CRP), and intestinal ultrasound showed bowel wall thickening, hyperemia and wall disruption, suggestive of an active flare. However, routine stool culture isolated Cryptosporidium, and based on her clinical background, oral paromomycin and azithromycin were initiated, resulting in complete clinical remission.
Cryptosporidiosis is a common parasitic cause of diarrhea, particularly affecting immunocompromised patients, such as those with HIV, cancer or solid organ transplants.²
Although few cases have been described in inflammatory bowel disease (IBD), the immunosuppressive state of these patients may increase the risk of infection. Diagnosing cryptosporidiosis in this population can be challenging, as stool tests detect only about 30% of cases, and the clinical presentation often mimics an IBD flare.³
Treatment is generally supportive and reserved for severe or refractory cases. Nitazoxanide is the drug of choice, and in non-responders, it can be combined with fluoroquinolones or azithromycin. In IBD patients, the decision to initiate specific antiparasitic treatment depends on the degree of immunosuppression and the clinical scenario.⁴
A clear association between IBD and cryptosporidiosis has not been established, but it is crucial to rule out opportunistic gastrointestinal infections in suspected flare-ups before starting specific therapies.
image "Bowel wall thickening, hyperemia, and disruption of the normal layer pattern."

References

(1) Janssen B, Snowden J. Cryptosporidiosis. 2023 Jul 10. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 28846353.
(2) Liu B, Schnider A, DeArmond M, Banach DB, Haubrich BA. Cryptosporidiosis in individuals with inflammatory bowel disease: a scoping review protocol. BMJ Open. 2024 Oct 15;14(10):e086529. doi: 10.1136/bmjopen-2024-086529. PMID: 39414295; PMCID: PMC11481120.
(3) Ferreira J, Baden R, Magge S, Cheifetz A. Cryptosporidiosis masquerading as a Crohn's flare. Inflamm Bowel Dis. 2011 Oct;17(10):E133-4. doi: 10.1002/ibd.21811. Epub 2011 Jul 7. PMID: 21739536.
(4) Manthey MW, Ross AB, Soergel KH. Cryptosporidiosis and inflammatory bowel disease. Dig Dis Sci 1997;42:1580–6.

Introduction

The Rutgeerts score, developed three decades ago, is used to assess postoperative endoscopic recurrence in patients with Crohn’s disease (CD) following ileocolonic resection with an end-to-end anastomosis.¹ However, contemporary surgical techniques have introduced new anatomical locations – the ileal body and ileal inlet – which were not accounted for in the original Rutgeerts score.² Additionally, the original Rutgeerts score has demonstrated limited inter-observer reliability.³ To address these limitations, an updated Rutgeerts score, incorporating new anatomical sites, has been proposed. According to the updated Rutgeerts score lesions restricted to the ileal inlet, or the ileal body can no longer be scored as i2a.² While the updated Rutgeerts score offers improved assessment of inflammation after an ileocolonic resection, its reproducibility has not yet been validated.

Aims & Methods

The aim of our study was to evaluate the inter- and intra-observer reliability of the updated Rutgeerts score.
We conducted a retrospective analysis of 183 patients with CD (48% male, median age 36.8 years) who underwent video-recorded ileocolonoscopy within 14 months of resection with ileocolonic anastomosis. An expert reader MF selected and scored videos of ileocolonoscopies, which were then used as the gold standard. After receiving a two-hour training with a set of ten videos eight expert gastroenterologists reviewed and scored the videos. Each reader assessed 92 videos, including 23 videos that were re-scored after at least one month. Based on the gold standard, inter- and intra-rater agreement was calculated across all score levels and for each score level. Inter-rater reliability was assessed using Fleiss' kappa, and intra-rater reliability using Cohen’s kappa, both with and without application of linear weights.

Results

The probability of perfect agreement between two readers across all scores was 0.604 (95% CI: 0.559-0.649). The chance-corrected inter-observer agreement based on Fleiss’ kappa with linear weights across all scores was 0.619 (95% CI: 0.562-0.676). The strongest inter-observer agreement was observed for the i2a score, with a value of 0.736 (95% CI: 0.647-0.826), while the weakest was seen for the i1 score (0.357, 95%CI: 0.225-0.489).
Intra-rater reliability with a Cohen’s kappa was 0.688 (0.609-0.767), and with weighted kappa was 0.831 (0.758-0.868). The overall agreement rate was 76.0% (69.1%-82.0%).

	Categorical		Ordinal
	Estimate	95%CI	Estimate	95%CI
All levels	0.604	(0.559;0.649)	0.882	(0.866;0.897)
i0	0.633	(0.467;0.800)	0.884	(0.824;0.945)
i1	0.357	(0.225;0.489)	0.829	(0.758;0.899)
i2a	0.736	(0.647;0.826)	0.925	(0.896;0.954)
i2b	0.502	(0.439;0.566)	0.856	(0.834;0.877)
i3	0.487	(0.351;0.623)	0.859	(0.798;0.920)
i4	0.715	(0.606;0.824)	0.894	(0.854;0.934)

Table 1. Summary of agreement across score levels: Agreement for all scores and by individual score levels, based on the gold standard (defined as the scores given by an expert reader MF). Categorical agreement reflects only perfect agreement. Ordinal agreement applies linear weights, assigning less weight to minor disagreements and more to larger ones.

Conclusion

The updated Rutgeerts score demonstrates good agreement and substantial inter- and intra-rater reliability in assessing postoperative endoscopic recurrence in CD, supporting its potential for broader adaptation in both clinical practice and research settings.

References

1. Rutgeerts P, Geboes K, Vantrappen G, Beyls J, Kerremans R, Hiele M. Predictability of the postoperative course of Crohn’s disease. Gastroenterology. 1990;99(4):956-963. doi:10.1016/0016-5085(90)90613-6
2. Rivière P, Bislenghi G, Vermeire S, et al. Postoperative Crohn’s Disease Recurrence: Time to Adapt Endoscopic Recurrence Scores to the Leading Surgical Techniques. Clin Gastroenterol Hepatol. 2022;20(6):1201-1204. doi:10.1016/j.cgh.2022.02.025
3. Marteau P, Laharie D, Colombel JF, et al. Interobserver Variation Study of the Rutgeerts Score to Assess Endoscopic Recurrence after Surgery for Crohn’s Disease. Journal of Crohn’s and Colitis. 2016;10(9):1001-1005. doi:10.1093/ecco-jcc/jjw082

Introduction

Crohn’s disease (CD) complicated with intra-abdominal abscess often requires surgical intervention. Image guided percutaneous drainage (PD) can help to avoid surgical interventions, however there is limited evidence on the optimal management after PD.

Aims & Methods

Our study aimed to analyze the long-term outcomes of CD complicated with intra-abdominal abscess after intervention. In this multicenter, interational retrospective trial penetrating CD patients with simplex intra-abdominal abscess were enrolled and followed until 12-24 months. Baseline was the day of the first detection of abdominal abscess. Patients with urgent resection were excluded. Patients were grouped based on elective surgical need during follow-up after a successful PD, while the control group consisted of patients who underwent resection without PD. Primary outcome was the abscess recurrence, while stoma rate, post procedural complications rate (<30 days), need for re-drainage and postoperative luminal recurrence were analyzed as secondary outcomes.

Results

A total of 151 CD patients from 9 countries were recruited and 86/151 patients had PD due to simplex abdominal abscess (Table 1.). Abscess recurrence rates were similar (12.8% vs. 7.7%, p=0.231). Need for re-drainage was more common amongst PD patients (OR=0.088, 95% CI=0.011-0.682), while hospital admission need was more frequent in control patients (OR=2.56, 95% CI=1.22-5.37). Postoperative luminal recurrence, new stoma, and biological treatment escalation needs were similar between groups based on PD. Surgical complications were coupled with increased odds in patients without prior PD (OR=3.3, 95% CI=1.09-10.0), septic complications, perforation and new fistula formation were reported the most, while PD associated complication did not occur. Higher baseline diameter of the abscess increased the odds for postoperative recurrence (OR=1.05, 95% CI=1.02-1.08) and new biological treatment initiation (OR=0.98, 95% CI=0.96-0.98). Elective resection was delayed after PD compared to control (24 vs 10 week, p=0.003). Time until resection increased the odds for redrainage (OR=1.03, 95% CI 1.01-1.05), and outcome was worse exceeding 17 weeks.

Variables	Total (n = 151)	PD group (n = 86)	Control group (n = 65)	Sig.
FU duration, weeks, median (IQR)	103 (71-109)	104 (64-112)	101 (77-105)	0.895
Sex, male (%)	88 (58.3)	49 (57.0)	39 (60.0)	0.419
Age at inclusion, years, median (IQR)	33.0 (26-44)	36.3 (27-46)	30.2 (25-38)	0.006
CD disease duration at inclusion, years, median (IQR)	11 (6-17)	11 (5-18)	11 (7-17)	0.916
Disease activity at baseline
CDAI, mean (± SD)	302 (109)	290 (126)	307 (115)	0.389
CRP, mg/l, mean (±SD)	92 (57)	112 (88)	107 (80)	0.753
SES-CD, mean (±SD)	10.0 (8.1)	7.1 (5.8)	12.0 (9.0)	0.071
Elective resection during FU, n (%)	126 (83.4)	61 (70.9)	65 (100)	-

Conclusion

The size of the abscess determines the outcomes, while surgical treatment alone may be associated with post-procedural complications. PD may delay resection; however, this delay can necessitate re-drainage.

Introduction

The majority of patients with Crohn`s disease (CD) undergo surgery at some point of their disease evolution. Timing of surgical procedure is currently at the centre of discussion, with the concept of surgery first showing promising results with regards to short-term quality of life and cost-effectiveness but it is unclear whether this approach can have long-term modifying effect on disease behaviour. With the enlargement of CD therapeutic armamentarium during the past years, the surgical procedure is often being delayed with unclear benefit for the patient.

Aims & Methods

The aim of this study was to determine whether the time to first surgery differ between patients with uncomplicated disease course compared with difficult-to-treat patients. All patients with CD followed at one tertiary IBD centre by March 2024 were identified through automated medical record system and patients with the history of IBD-related surgery were further analysed. Basic demographics, disease phenotype, surgical procedures and biologic use were retrieved from medical records. Surgical procedure of interest for this study purpose was defined as bowel resection of any localisation, stricturoplasty, proctectomy, gastro-enteroanastomosis. Patients with more than one surgical procedure and/or two or more biologics were categorized as difficult-to-treat; patients with one surgical procedure and no or one biologic were considered as patients with uncomplicated disease course. The differences in basic demographics, disease phenotype and time to surgery between the two groups were analysed statistically.

Results

In total 152 patients with a history of CD-related surgery were included; mean age 40 years (range 19-81), 57 (38%) men, mean duration of the disease 14,9 years (range 1-42), the majority of patients had stenosing or stenosing and penetrating disease behaviour (54% and 33%, respectively) and ileal or colonic localisation (53% and 38%, respectively). Thirty-nine patients (26%) had history of two or more surgeries.
Seventy-seven patients (51%) were considered as difficult-to-treat, there were no differences in disease localisation and behaviour between these patients and patients with uncomplicated disease course. Time to surgery was significantly longer in the difficult-to-treat group (6.5 ± SD 5.6 yrs) compared with the patients with uncomplicated disease course (3.8 ± SD 5.5 yrs); p=0.003. Among patients with uncomplicated disease course, significantly higher proportion of patients have been operated during the first year after diagnosis compared with difficult-to-treat patients (38 pts, 51% vs. 18 pts, 23%; p=0.000488).

Conclusion

Difficult-to-treat patients with Crohn`s disease have significantly longer time to surgery than patients with uncomplicated disease course. Considering the finding that these two groups do not differ in disease phenotype as risk factor for difficult-to-treat disease, delayed first surgery might be an independent factor for complicated disease course in these patients at long term.