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Edward V Loftus

Publications and source records attributed to Edward V Loftus.

68 records · Page 4Linked to original sources
PubMed2002

The natural history of fistulizing Crohn's disease in Olmsted County, Minnesota.

BACKGROUND & AIMS: Little is known about the cumulative incidence and natural history of fistulas in Crohn's disease in the community. METHODS: The medical records of all Olmsted County, Minnesota residents who were diagnosed with Crohn's disease from 1970 to 1993 and who developed a fistula were abstracted for clinical features and outcomes. Six patients denied research authorization. The cumulative incidence of fistula from time of diagnosis was estimated by using the Kaplan-Meier product-limit method. RESULTS: At least 1 fistula occurred in 59 patients (35%), including 33 patients (20%) who developed perianal fistulas. Twenty-six (46%) developed a fistula before or at the time of formal diagnosis. Assuming that the 9 patients with fistula before Crohn's disease diagnosis were instead simultaneous diagnoses, the cumulative risk of any fistula was 33% after 10 years and was 50% after 20 years (perianal, 21% after 10 years and 26% after 20 years). At least 1 recurrent fistula occurred in 20 patients (34%). Most fistulizing episodes (83%) required operations, most of which were minor. However, 11 perianal fistulizing episodes (23%) resulted in bowel resection. CONCLUSIONS: Fistulas in Crohn's disease were common in the community. In contrast to referral-based studies, only 34% of patients developed recurrent fistulas. Surgical treatment was frequently required.

Adolescent↗
PubMed2002

Long-term fracture risk in patients with Crohn's disease: a population-based study in Olmsted County, Minnesota.

BACKGROUND & AIMS: Osteoporosis is common in patients with Crohn's disease, but less is known about their risk of actual fractures. METHODS: The medical records of all 238 Olmsted County, Minnesota, residents diagnosed with Crohn's disease between 1940 and 1993 were reviewed for evidence of subsequent fractures compared with a control group of county residents matched by age and sex. The risk ratio of fracture in patients relative to controls was estimated using the Cox proportional hazards regression model. The cumulative incidence of fracture following diagnosis was estimated using the Kaplan-Meier method. RESULTS: Sixty-three patients had 117 different fractures. The cumulative incidence of any fracture from the time of diagnosis onward was 36% at 20 years versus 32% in controls (P = 0.792). Compared with controls, the overall risk ratio for any fracture was 0.9 (95% confidence interval [CI], 0.6-1.4), whereas the relative risk for an osteoporotic fracture was 1.4 (95% CI, 0.7-2.7). The risk ratio for thoracolumbar vertebral fracture was 2.2 (95% CI, 0.9-5.5). Cox proportional hazards regression identified only age as a significant clinical predictor of fracture risk (hazard ratio per 10-year increase in age, 1.3; 95% CI, 1.1-1.5). Specifically, use of corticosteroids and surgical resection did not predict risk of fracture among these unselected patients with Crohn's disease from the community. CONCLUSIONS: In this population-based inception cohort of patients with Crohn's disease, the risk of fracture was not elevated relative to age- and sex-matched controls.

Adolescent↗
PubMed2002

Constrictive pericarditis in chronic ulcerative colitis.

Acute pericarditis has been described as an extraintestinal manifestation of inflammatory bowel disease (IBD), as well as a consequence of IBD treatment, specifically sulfasalazine and mesalamine. Until now, there have been no reported cases of constrictive pericarditis associated with IBD or its treatment. A 37-year-old woman with a 24-year history of chronic ulcerative colitis (CUC) presented with a 3-month history of fevers, palpitations, dyspnea, syncope, and retrosternal chest pain. Two weeks before symptoms, she had initiated oral mesalamine for an ongoing CUC flare. Physical examination suggested constrictive pericarditis. An echocardiogram revealed a thickened pericardium with a nearly circumferential fibrinous effusion, with Doppler confirming diastolic compromise. The patient proceeded to radical pericardectomy. Pathological examination showed grossly hemorrhagic acute and chronic pericarditis, with cultures and cytology negative. To date, only 104 cases of IBD with acute pericarditis have been reported, with fewer than 10 cases of mesalamine-induced acute pericarditis reported. This is the first reported case of constrictive pericarditis related to IBD or its treatment. Although our patient may have had IBD-associated constrictive pericarditis, her mesalamine use raises the possibility of a drug-induced constrictive pericarditis.

Adult↗
PubMed2002

Delayed hypersensitivity reaction and acute respiratory distress syndrome following infliximab infusion.

Infliximab, a chimeric human/murine monoclonal antibody directed against the proinflammatory cytokine tumor necrosis factor alpha, is an effective therapy for Crohn's disease (CD) and rheumatoid arthritis refractory to standard medical treatment. We report a case of adult respiratory distress syndrome associated with infliximab therapy. A 33-year-old white male presented with an exacerbation of CD and was treated with his second infliximab infusion (15 months following the first infusion). Within 7 days he developed arthralgias, myalgias, and fever, followed by respiratory failure. He required intubation and mechanical ventilation. Open lung biopsy demonstrated eosinophilic pneumonia. Human antichimeric antibodies were present at high concentrations. An extensive investigation for infectious etiologies was negative. The patient was treated with intravenous corticosteroids, and fully recovered after a prolonged hospitalization. We review the infectious and immunologic complications of infliximab.

Adult↗
PubMed2002

Azathioprine or 6-mercaptopurine before colectomy for ulcerative colitis is not associated with increased postoperative complications.

AIM: To determine whether the use of azathioprine/6-mercaptopurine before colectomy is associated with an increased rate of postoperative complications. METHODS: All patients who underwent colectomy with ileal pouch-anal anastomosis for ulcerative colitis between 1997 and 1999 were identified. Medical records were abstracted for demographics, extent and duration of disease, dose and duration of corticosteroids and azathioprine/6-mercaptopurine, albumin, and Truelove/Witts score. Early (30-day) and late (6-month) complications were identified. Noncorticosteroid immunosuppressive use was coded as none, azathioprine/6-mercaptopurine within 1 week of surgery, or therapy with other immunosuppressive agents within 1 month of surgery. A logistic regression analysis assessed the association between these variables and complications. RESULTS: Early complications occurred in 49 of 151 (32%) patients not treated with immunosuppressive agents, 12 of 46 (26%) azathioprine/6-mercaptopurine-treated patients, and 4 of 12 (33%) patients treated with other immunosuppressive agents (p = 0.71). Late complications occurred in 72 of 148 (49%), 20 of 46 (43%), and 8 of 12 (67%) patients in these same groups, respectively. Intravenous or oral steroids at doses of 40 mg/d or greater (p < 0.01) and severe or fulminant disease (p = 0.0094) were associated with greater early complication rates. CONCLUSION: Early complications after restorative proctocolectomy for ulcerative colitis are associated with high dose steroids and severe disease but not use of azathioprine/6-mercaptopurine.

Adolescent↗
PubMed2002

Safety of selective cyclooxygenase-2 inhibitors in inflammatory bowel disease.

OBJECTIVES: Nonsteroidal anti-inflammatory drugs (NSAIDs) are relatively contraindicated in patients with inflammatory bowel disease (IBD) for fear of disease aggravation. Cyclooxygenase-2 inhibitors have fewer GI side effects than traditional NSAIDs in unselected patients. We report the safety of these agents in patients with IBD. METHODS: Patients with Crohn's disease, ulcerative colitis, or pouchitis who used celecoxib or rofecoxib were identified from computerized prescription records. A retrospective chart review was conducted. Concomitant medications, past NSAID use, indication for cyclooxygenase-2 inhibitor, dose, and duration were obtained. IBD disease activity before cyclooxygenase-2 inhibitor use was graded using a modified disease activity index. Change in disease activity was graded as improved, no change, or worsened. Patients were contacted to provide data not found in the charts. The proportion of patients receiving cyclooxygenase-2 inhibitors who experienced exacerbation of IBD was determined. RESULTS: Eleven patients were treated with celecoxib (median dose = 200 mg/day), and 16 patients were treated with rofecoxib (median dose = 25 mg/day). Median duration of therapy was 9 months (range = 1 wk-22 months). The drug was beneficial in 14 patients, of partial benefit in eight, and of no benefit in five. Two patients (7.4%) (95% CI = 2-23%) had aggravations of IBD. Three patients (11%) had other adverse events (renal insufficiency, rash, and asymptomatic colonic ulceration). All adverse events were reversible. CONCLUSIONS: Our preliminary results suggest that cyclooxygenase-2 inhibitors may be safe and beneficial in most patients with IBD. A placebo-controlled trial to confirm these preliminary observations is needed.

Adult↗
PubMed2002

The fate of low grade dysplasia in ulcerative colitis.

OBJECTIVE: The optimal strategy for the management of definite low grade dysplasia (LGD) detected in surveillance in ulcerative colitis (UC) is unknown, because the natural history of LGD has not been well described. METHODS: We reviewed the Mayo Clinic records of patients with UC found to have flat LGD between 1990 and 1993 in whom a nonoperative strategy was pursued for 2 months or more. RESULTS: Eighteen patients with UC and LGD were observed for a median of 32 months. Nine of 18 patients identified with UC and LGD developed advanced neoplastic lesions during follow-up, which were defined as adenocarcinoma, raised dysplasia, or high grade dysplasia. The cumulative incidence of progression to an advanced lesion was 33% at 5 yr (95% CI = 9-56%). Only one patient developed adenocarcinoma, diagnosed 74 months after his initial finding of LGD and 20 months after his last surveillance exam. Besides this patient, adenocarcinoma was not detected in the colectomy specimens of 13 other patients who underwent surgery. Colectomies were performed for dysplasia or cancer in seven patients, active colitis in five patients, and unknown reasons in two patients. Four patients did not have colectomies. CONCLUSIONS: Neoplastic progression in patients with UC and LGD is common. Total proctocolectomy should be offered to all patients with flat LGD. Our study illustrates numerous pitfalls in the practice of surveillance.

Adult↗
PubMed2002

N-acetyltransferase 1 and 2 genotypes do not predict response or toxicity to treatment with mesalamine and sulfasalazine in patients with ulcerative colitis.

OBJECTIVES: 5-Aminosalicylate is metabolized in colonic mucosa by N-acetyltransferase 1 (NAT1), and sulfapyridine is metabolized in the liver by N-acetyltransferase 2 (NAT2). Common genetic polymorphisms in these enzymes result in rapid and slow acetylation. We determined the association between NAT1 genotype and response to mesalamine and sulfasalazine, as well as between NAT2 genotype and toxicity to sulfasalazine, in a population-based cohort of patients with ulcerative colitis. METHODS: DNA was obtained from 77 white patients with ulcerative colitis from Olmsted County, MN. NAT1 and NAT2 genotyping was performed using microelectronic array devices. Phenotypes were deduced from previously published genotype/phenotype correlations. Clinical response to mesalamine and sulfasalazine, and toxicity to sulfasalazine, were determined by medical record review and associated with NAT1 and NAT2 genotypes. RESULTS: The clinical response rates among 52 patients treated with mesalamine were 67% (31 of 46) for rapid acetylators and 83% (five of six) for slow acetylators (odds ratio = 0.4, 95% CI = < 0.1-3.9, p = 0.65). Similarly, the clinical response rates among 64 patients treated with sulfasalazine were 74% (43 of 58) for rapid acetylators and 67% (four of six) for slow acetylators (odds ratio = 1.4, 95% CI = 0.2-8.6, p = 0.65). The toxicity rates among the 64 patients treated with sulfasalazine were 34% (12 of 35) for slow acetylators and 45% (13 of 29) for rapid acetylators (odds ratio = 0.6, 95% CI = 0.2-1.8, p = 0.65). CONCLUSIONS: NAT1 and NAT2 genotypes did not predict response to mesalamine or sulfasalazine, or toxicity to sulfasalazine.

Adolescent↗
PubMed2002

Fistulas to the urinary system in Crohn's disease: clinical features and outcomes.

OBJECTIVES: Most reports of fistulas to the urinary system in Crohn's disease are relatively small. We sought to describe the clinical features and outcomes of these patients. METHODS: A centralized diagnostic index identified all Crohn's disease patients with urinary tract fistulas who were evaluated at our institution between 1976 and 2000. Medical records were abstracted for patient demographics, presenting symptoms, diagnostic tests, and all therapies. RESULTS: A total of 78 patients (56% men) were identified. Patients presented with pneumaturia (68%), dysuria (64%), recurrent urinary tract infections (32%), and fecaluria (28%). Cystoscopy and CT of the abdomen/pelvis had the highest diagnostic yield (74% and 52%, respectively). Fistulas originated from the ileum (64%), colon (21%), rectum (8%), and multiple sites (7%). Urinary tract sites included bladder (88%), urethra (6%), urachus (3%), ureter (1%), and other (1%). Median follow-up was 1.1 yr (0-22.3 yr). A total of 70 patients (90%) had surgery, with medical treatment first attempted in four patients with antibiotics and/or immunosuppressants. One patient had adequate symptom relief without surgery on antibiotic suppression alone. Six patients required a partial cystectomy, but no patient had a cystectomy or nephrectomy. Only three surgical patients had recurrent urinary system fistulas. CONCLUSIONS: Urinary tract fistulas in Crohn's disease occurred more often in men. Patients with these fistulas presented with pneumaturia, dysuria, recurrent infections, and fecaluria. The most helpful diagnostic tests were cystoscopy and CT of abdomen/pelvis. Surgery resulted in durable remission. Medical therapy for these fistulas deserves further study.

Adolescent↗
PubMed2002

Lymphocytic colitis: clinical features, treatment, and outcomes.

OBJECTIVE: There are no reports of the clinical features or treatment outcomes in large series of patients with lymphocytic colitis, and it is not known whether treatments that appear to be beneficial in patients with collagenous colitis are also beneficial in lymphocytic colitis. We sought to analyze these issues in our patients with lymphocytic colitis. METHODS: All patients with biopsy-proven lymphocytic colitis evaluated at our institution between January 1, 1997, and December 31, 1999, were identified. Clinical features on presentation and treatment outcomes were abstracted from the medical records. RESULTS: A total of 170 patients with lymphocytic colitis were identified (median age 67 yr, 61% female). Diarrhea, bloating, rectal urgency, fecal incontinence, weight loss, concomitant autoimmune disorders, and aspirin or nonsteroidal anti-inflammatory drug use were common. Loperamide, diphenoxylate/atropine, and bismuth subsalicylate were effective therapies and were well tolerated. However, no therapy produced a complete response in more than 40% of patients. CONCLUSIONS: Lymphocytic colitis typically presents in elderly patients as chronic diarrhea. Nocturnal stools, urgency, and abdominal pain occur frequently, as do weight loss, fecal incontinence, and concomitant autoimmune disorders. Many empiric treatment options are used, but overall response rates are disappointing. Randomized controlled trials are needed to determine the optimum therapeutic approach to these patients.

Adolescent↗
PubMed2002

Treatment of inflammatory bowel disease in the elderly: an update.

Inflammatory bowel disease (IBD) is most common in young adults, but it can also present in the elderly. Furthermore, with the aging of the population, the number of elderly patients with IBD is expected to grow. Other conditions, such as diverticulitis and ischaemic colitis, may be more common in the elderly and need to be considered in the differential diagnosis. Management of elderly patients with IBD follows the same principles as in younger patients, with a few exceptions. For patients with mild-to-moderate colitis, a 5-aminosalicylate drug is often used (sulfasalazine, olsalazine, mesalazine, balsalazide). Topical therapy may be sufficient for those with distal colitis, whereas an oral preparation is used for more extensive disease. In those with more severe or refractory symptoms, corticosteroids are used, although the elderly appear to be at increased risk for corticosteroid-associated complications. For patients with corticosteroid-dependent or corticosteroid-refractory disease, immunosuppression with azathioprine or mercaptopurine may help avoid surgery. In patients with Crohn's disease, a similar approach is followed, with the additional consideration that the formulation of drug used must ensure delivery of drug to the site of inflammation. In fistulising Crohn's disease, antibacterials, immunosuppressive drugs, infliximab and surgery are often used in combination. Controlled trials and clinical experience have shown that infliximab is a significant addition to the therapeutic armamentarium for patients with Crohn's disease.

Aged↗
PubMedDate not supplied

Does monitoring prevent cancer in inflammatory bowel disease?

Surveillance colonoscopy for patients who have inflammatory bowel disease with colonic involvement has gained widespread acceptance. From an evidence-based perspective, however, the foundation for this practice remains weak. There are no randomized controlled trials, prospective cohort studies, or case-control studies that definitively prove a benefit for surveillance colonoscopy (i.e., reduction in colorectal cancer-related mortality). Nevertheless, circumstantial evidence indirectly suggests a benefit. This article reviews risk factors for colorectal cancer in inflammatory bowel disease and the evidence supporting the practice of colonoscopic surveillance. The benefits of frequent physician visits and compliance with medication regimens with regard to reduction in colorectal cancer risk are also reviewed.

Colonoscopy↗