Introduction

Coeliac disease is an autoimmune disease that affects the small bowel in genetically predisposed people precipitated by the ingestion of gluten. Worldwide prevalence has been estimated at around 1%.

Aims & Methods

To screen for coeliac disease using a point of care (POC) testing kit in a random cohort of asymptomatic people in the Maltese Islands, where no prevalence study data is available.
A random sample of people aged 18-75 years were invited to participate and were tested using the professional Biocard™ Celiac Test. This is a rapid immune chromatographic lateral flow test for the qualitative detection of anti-tissue transglutaminase IgA antibodies (TTG IgA) from a fingertip blood sample. All the results were read by the same gastroenterologist within 10minutes. This test also measures total IgA measuring the presence of IgA antibodies in the sample which reduces the risk of false negatives due to IgA deficiency. Patients with a positive test were offered serological blood tests to check the level of TTG IgA and antiendomysial antibodies (EMA) and an oesophagogastroduodenoscopy (OGD) with duodenal bulb and 2^nd part of the duodenum biopsies.

Results

1251 people were tested using the point of care test (52.6% Female, Mean Age 41.2; SD +/-11.4).
9 patients (0.7%) had a low IgA level, 4 patients underwent serological testing for IgA and a TTG IgG and confirmed the low IgA and a negative TTG IgG result. The rest refused the tests.
9 patients (0.7% of the screened cohort) (77.8% female, p=0.13) had a positive POC test. From these, 1 patient refused further serological tests or an OGD. 87.5% (7/8 patients) were confirmed to have coeliac disease and these all had a TTG IgA level >100Iu/mL or more than 10 times the upper limit of normal (Normal range0.1-9.0 IU/mL) and also a strongly positive EMA of 3+. 1 patient had an OGD with normal biopsies as well as a TTG IgA level ≤30iu/mL or less than three times the upper limit of normal. The EMA level was weakly positive (1+). Marsh classification for the confirmed cases showed 55.6% Marsh 3b, 44.4% with Marsh 3c.

Conclusion

The prevalence of coeliac disease in adults in the Maltese Islands using a point of care test is 0.7%. On further testing with confirmatory duodenal biopsies, 0.56% (7/1250 patients) of patients were confirmed to have CD on duodenal biopsies. This confirms that duodenal biopsies are still required in patients whose TTG IgA levels are <10 the upper limit of normal. Furthermore, the clinical question arises of how patients with positive coeliac serology which is <10 the upper limit of normal, positive genetic studies and normal duodenal biopsies be followed up.

Disclosure

Dr Sciberras received funding from Dr. Schär

Introduction

Microscopic colitis (MC) is an inflammatory gastrointestinal disease which typically presents with chronic watery diarrhea without blood. Despite a rising incidence over the last decades (1), studies on health economic outcomes are lacking.

Aims & Methods

In this cost-of-illness study, we estimate the societal economic burden of MC encompassing costs for healthcare, medications, and work loss, by the use of real-world data from Swedish health registers.
Through biopsy reports from Sweden’s 28 pathology departments, we identified 11,530 adult patients with MC as of January 1, 2017. Each patient was compared to up to 5 general-population comparators matched on date of birth, sex, and county of residence. Healthcare costs were based on prescription medications as well as non-primary outpatient visits and hospitalizations that included endoscopic procedures, while productivity losses were derived from work loss due to sick leave or disability leave. Mean differences were adjusted for age, sex, and education level. All costs were adjusted for inflation and converted from Swedish currency, SEK, to USD according to the annual average conversion rate in 2016 (1 USD = 8.5613 SEK or 0.9040 EUR).

Results

In 2016, patients with MC had a mean annual cost of $11,782 as compared with $6,170 in general-population comparators, corresponding to an annual excess cost of $5,615 per patient (adjusted mean difference $5,628 [95%CI: $5,278-$5,978], Table 1).
Even though less than half of the patients with MC were of working age (18-64 years, 42.5%), work loss was the largest cost component and accounted for more than half of the mean annual excess cost (57.7%). Excess costs related to hospitalizations accounted for 18.1%, whereas costs related to outpatient visits and medications accounted for 12.6% and 13.4% respectively. Although patients with MC had an increased use of MC-related medications such as local acting steroids (ATC code A07EA), these costs were comparatively small (mean annual cost, $106). Furthermore, MC-related healthcare costs such as colonoscopies, or outpatient visits and hospitalizations related to MC as defined by ICD code K.528, were negligible (mean annual cost, $68, $72 and $15 respectively).
The total annual societal cost of MC in Sweden was $135.9 million in 2016. By subtracting the baseline cost observed in general-population comparators, $64.7 million was found to be attributable to MC and MC-comorbidity.

Table 1. Use and cost of healthcare, prescription medications, and work loss in prevalent patients with microscopic colitis (MC) and general-population comparators in Sweden, 2016.

Conclusion

Patients with MC had an increased mean annual societal cost which was primarily driven by work loss. Healthcare costs specifically related to MC did not seem to be a major contributor to excess costs. Instead, excess healthcare costs in patients with MC are likely to be driven by concomitant disease. The societal economic burden of MC in Sweden was $135.9 million in 2016 with a population of 10.0 million and a prevalence of around 0.1%.

References

1. Bergman D, Clements MS, Khalili H, Agréus L, Hultcrantz R, Ludvigsson JF. A nationwide cohort study of the incidence of microscopic colitis in Sweden. Aliment Pharmacol Ther. 2019 Jun;49(11):1395-1400.

Disclosure

Dr Ludvigsson coordinates a study on behalf of the Swedish IBD quality register (SWIBREG). That study has received funding from the Janssen corporation. Dr Ludvigsson has also received financial support from MSD to develop a paper reviewing national healthcare registers in China.

Introduction

Inflammatory bowel diseases (IBD) are chronic systemic conditions that affect patients' lives in various ways. To date, there is a scarce evidence correlating fecal incontinence, sexual dysfunctions, disease activity, and quality of life (QoL) in these patients. This study aimed to evaluate the impact of fecal incontinence on sexual functions such as erectile and prostatic function in a cohort of IBD patients; and to analyse the relationship among fecal incontinence, sexual function and QoL.

Aims & Methods

IBD patients were enrolled from IBD clinic of the Gastroenterology Unit of the University Hospital of Salerno. Demographic characteristics, anthropometric data, and usage of immunosuppressive drugs were collected. Patients underwent a physical examination, and laboratory tests, including C-reactive protein (CRP) and fecal calprotectin (FC). A standardized questionnaire was used to assess gastrointestinal (GI) symptoms such as abdominal pain and fecal incontinence. For the latter, we also used the Wexner score. Crohn's Disease Activity Index (CDAI) and Mayo score as well as FC levels, and endoscopic findings were used to classify IBD patients as in active or in remission phase. Patients with perianal manifestations were excluded. Hormonal values (FSH, LH, Prolactin, 17-betaestradiol, testosterone) were measured. Sexual function was evaluated using the International Index of Erectile Function (IIEF), Male Sexual Health Questionnaire (MSHQ), Ejaculatory Dysfuction (EjD), prostatic dysfunction using the National Institute of Health - Chronic Prostatitis Symptom Index (NIH-CPSI) and International Prostatic Symptoms Score (IPSS). QoL was assessed by FiQol domains (lifestyle, coping behaviour, self‐perception and depression, embarrassment).

Results

Eighty-five male IBD patients (47 Crohn's disease [CD] and 38 ulcerative colitis [UC]), were enrolled. Mean age was 43.7 ± 15.9 years; mean BMI was 36.4±25.5 Kg/m². Twenty-four CD patients had an active disease and 23 were in remission, while 20 UC patients had an active disease and 18 were in remission. UC patients showed significantly higher fecal incontinence and Wexner scores compared to CD patients (1.0±1.9 vs 0.4±1.2, p=0.05 and 2.84±4.2 vs 2.3±1.1, p=0.01, respectively). Only the Mayo score significantly correlated with Wexner score (Rs=0.578; p<0.001), and fecal incontinence (Rs=0.584; p<0.001). Sexual function, evaluated by erectile and prostatic scores, nicely correlated each other’s (p<0.05 in all cases). However, no association was found between fecal incontinence and all sexual function scores. The FiQol domain self‐perception and depression was significantly associated with IIEF (p=0.01).

Conclusion

This study highlighted the prevalence of fecal incontinence is higher in UC than CD patients. However, fecal incontinence did not impact on sexual function, evaluated by erectile and prostatic scores. QoL influenced erectile function.

Introduction

Gender-specific differences in adult patients with immune mediated diseases like inflammatory bowel diseases (IBD) or coeliac diseases are increasingly recognised (1). In paediatric patients, gender differences in the incidence of IBD have been identified in a pooled analysis of population-based studies (2). However, gastrointestinal (GI) symptoms associated with paediatric IBD or coeliac disease and possible gender differences in GI symptoms have not been systematically studied.

Aims & Methods

Our aim was to utilise the newly developed, validated paediatric Structured Assessment of Gastrointestinal Symptoms (pSAGIS) scale to systematically assess GI symptoms in children with Crohn’s disease, ulcerative colitis, and coeliac disease by gender in an paediatric gastrointestinal outpatient clinic.
The pSAGIS is a patient-reported outcome measure (PROM) that consists of 21 GI-related questions and assesses the type and five severity grades of symptoms.
pSAGIS scales were completed by patients or their caregivers attending the GI outpatient unit of St. Anna Children’s Hospital, Vienna, Austria between the years 2016 and 2020. The diagnoses of patients were established on clinical terms after a complete examination deemed clinically necessary. Based on pSAGIS, an overall GI-symptom score was calculated as the sum of each individual symptom score for patients with Crohn’s disease, ulcerative colitis and coeliac disease, and symptom scores were compared between female and male patients. In addition, GI symptoms were summarised in five symptom groups (abdominal pain, dyspepsia, diarrhea, constipation, dysphagia/nausea). Data are given as mean ± standard deviation (SD), a p-value <0.05 was considered significant.

Results

From 3344 collected pSAGIS questionnaires 12.9% (n=430) were completed by children diagnosed with Crohn’s disease (71.9% male, 28.1% female), 9.0% (n=302) with ulcerative colitis (57.0% male, 43.0% female), and 24.7% (n=827) with coeliac disease (36.4% male, 63.6% female). In patients with Crohn’s disease the overall GI-symptom score was significantly higher among female patients comparing to male patients (7.3±10,1 vs. 2. 8±4,2, p<0.001) while in patients with ulcerative colitis overall symptom scores were higher in male than in female patients (5.6±8.5 vs 2.9±5.9; p=0.002). The table shows scores of symptom groups in patients with Crohn's disease and ulcerative colitis. The overall GI symptom score was low in patients with coeliac disease, and no significant differences were found between male and female coeliac patients (3.1±4.6 vs. 3.9±6.4, p=0,064).

Conclusion

Gender specific symptoms and symptom burden exist in paediatric patients with Crohn’s disease and ulcerative colitis. These gender differences may affect time to diagnosis, initiation of treatment and adherence to treatment and need further investigation. The pSAGIS is an easy adjunct to gastrointestinal history taking and allows a valid and systematic symptom assessment in a paediatric outpatient clinic.

References

(1) Greuter T et al, Digestion 2020; (2) Shah SC et al, Gastroenterology 2018