Society: AGA

Background: Patients with inflammatory bowel disease (IBD) often modify their diet in attempt to manage their disease and symptoms. In some cases, dietary changes involve excessive restriction, which may place patients at risk for adverse consequences. Avoidant Restrictive Food Intake Disorder (ARFID) is a non-body image based eating disorder that involves restrictive eating and has been suggested to disproportionately affect patients with IBD. However, true rates of ARFID are not yet known, as no study to date has applied ARFID diagnostic criteria. The aims of the current study were (1) to identify the prevalence of IBD patients screening positive for ARFID and (2) explore associations between psychosocial and disease-related factors with ARFID symptoms.
Methods: Adult patients with confirmed IBD were invited to complete electronic questionnaires at two academic medical centers. The ARFID subscale of the Pica, ARFID, and rumination disorder questionnaire (PARDI-AR-Q) was used to categorize patients as screening positive for ARFID. The nine-item ARFID Screen (NIAS) was used to measure ARFID symptom severity. Additional survey items included demographic and disease information, the Visceral Sensitivity Index (VSI), Patient Health Questionnaire-4 (PHQ-4) for anxiety and depression, and the NIH-PROMIS Global Health Questionnaire for mental and physical health. The Harvey Bradshaw Index (HBI) and Patient-Reported Outcome (PRO-2) were used to characterize disease activity in Crohn’s disease (CD) and ulcerative colitis (UC), respectively. Descriptive statistics and Pearson’s correlations were used to analyze sample data.
Results: A total of 258 patients (55.8% female, mean age 47.6 (17)) responded to the survey, of which 136 (53%) had CD and 122 (47%) had UC. 40% of the sample had active disease. ARFID scores are presented in table 1. 17% of the sample screened positive for ARFID with significantly more patients with CD screening positive compared to UC (23.4% vs. 11.1% respectively, p = .012). Patients with active disease were more likely to screen positive for ARFID compared to inactive disease (25.3% vs. 12.4% respectively, p = .011). Higher ARFID scores based on NIAS were associated with higher scores on PHQ-4 anxiety (r = .13, p < .05), VSI (r = .47, p < .001), and PROMIS mental and physical health (r = .30, p < .001 and r = .30, p < .001 respectively).
Conclusions: 17% of tertiary care IBD patients in this multisite study screened positive for ARFID based on a validated screening questionnaire that corresponds with DSM-5 criteria. Disease type and severity placed patients at higher risk for ARFID. Greater ARFID symptomatology was associated with more GI-specific anxiety and quality of life impairment. These findings highlight the need for adequate screening, education, and treatment to prevent and manage ARFID in patients with IBD.

Background:
Patients with ulcerative colitis (UC) report that UC negatively affects their quality of life (QoL), including sexual functioning, satisfaction, and drive.¹^,2 These effects are rarely discussed with or by gastroenterologists in clinical practice. The CONFIDE study aims to elucidate the impact of symptoms on the lives of patients with moderate-to-severe UC in the United States (US), Europe (EU5; France, Germany, Italy, Spain, and UK), and Japan. Data presented here are from the US and EU5.
Methods:
Online, quantitative, cross-sectional surveys were conducted (July–September 2021). Criteria based on previous treatment, steroid use, and/or hospitalization were used to define moderate-to-severe UC. Data collected included patient perspectives on the impact of UC on sexual activity. Sexual activity was not limited to intercourse and included activities such as masturbation.
Results:
Surveys were completed by 200 US patients (male [M]=62%, mean age 40 years) and 556 EU5 patients (M=57%, mean age 39 years). Of these, 77% US and 54% EU5 patients were receiving advanced therapy (biologic/novel oral) and 52% and 73% were receiving steroids at the time of survey completion, respectively. Overall, 63% US patients (M=55%, female [F]=77%) and 53% EU5 patients (M=47%, F=60%) reported avoiding or decreasing sexual activity due to UC in the 3 months prior to the survey (Figure 1a). Among these patients (US: N=126; EU5: N=292), most frequently reported reasons for avoidance of sexual activity were bowel urgency (BU; 41%), decreased sexual desire (37%), and fear of BU-related accidents (34%) in the US and fear of faecal seepage (37%), fear of BU-related accidents (36%), and BU itself (31%) in EU5 (Figure 1b). Although reasons for avoiding sexual activity were broadly similar between sexes, higher percentage of male patients from both US and EU5 (US: M=33%, F=24%; EU5: M=42%, F=33%) reported fear of faecal seepage as a factor affecting sexual activity. Conversely, higher percentages of female patients reported perianal pain (M=13%, F=19%) and self-consciousness (M=13%, F=24%) as reasons for avoiding sexual activity in the US and decreased sexual desire (M=16%, F=26%), BU (M=26%, F=36%) and fatigue (M=14%, F=22%) in EU5 (Figure 2).
Conclusions:
In both US and EU5 populations, >50% patients with moderate-to-severe UC reported avoiding or decreasing sexual activity due to UC, with bowel urgency and bowel urgency-related accidents being among the top three reasons. In addition to other QoL parameters, impact of UC on patients’ sexual health needs to be assessed in routine clinical practice.
References:
¹Bulut AE, et al. Turk J Gastroenterol. 2019;30:33-39.
²Jedel S, et al. Inflamm Bowel Dis. 2015;21:923-38.

<b>Figure 1:</b> Impact of ulcerative colitis (UC) on sexual activity. (a) Patients (%) who avoided or decreased sexual activity in the last three months due to UC. (b) Patient-provided reason(s) for avoiding or decreasing sexual activity in the last three months because of UC.

Figure 1: Impact of ulcerative colitis (UC) on sexual activity. (a) Patients (%) who avoided or decreased sexual activity in the last three months due to UC. (b) Patient-provided reason(s) for avoiding or decreasing sexual activity in the last three months because of UC.

<b>Figure 2</b>: Proportion of male and female patients reporting each reason for avoiding sexual activity in the last three months (among patients who reported avoiding or decreasing sexual activity due to UC). (a) US patients (b) EU5 patients.

Figure 2: Proportion of male and female patients reporting each reason for avoiding sexual activity in the last three months (among patients who reported avoiding or decreasing sexual activity due to UC). (a) US patients (b) EU5 patients.

Introduction: Anxiety and depression are highly prevalent among individuals with inflammatory bowel disease (IBD) and are associated with increased hospitalization, disease flares, and complications. However, little is understood about how social determinants of health (SDOH) may impact mental health diagnoses in this population. The Centers for Disease Control’s social vulnerability index (SVI) provides neighborhood-level estimates of social need with higher values on a 0-1 scale indicating greater social vulnerability. We aimed to examine the relationship between SDOH (as measured by census tract-level SVI) and comorbid depression and anxiety in patients with IBD.

Methods: We used an established longitudinal cohort of patients with IBD cared for at a single center between 2015 and 2022. Patients were geocoded to individual census tracts based on their current address and linked to a corresponding SVI and subscales (Figure 1). Data was collected from standardized mental health screening questionnaires to determine if patients had been ever been screened for depression and anxiety. We used multivariable logistic regression to examine the relationship between comorbid depression and anxiety and census tract-level SVI, while adjusting a priori for IBD type, age, gender, race, ethnicity, marital status, language, religion, and medical comorbidities.

Results: 13,301 patients with IBD were identified, among which 17% had comorbid depression and 18% had comorbid anxiety based on electronic health record data. However, the percent of individuals screened for depression and anxiety where much lower (15% and 8%, respectively). Those patients with a higher SVI (> 0.5) were also less likely to be screened for depression (9.9% vs 17%, p<0.001) and anxiety (5.8% vs 9.1%, p<0.001) compared to those with lower SVI (<0.5). A higher SVI was associated with a higher likelihood of depression (OR 1.23, 95% CI 1.02-1.47. p <0.03. (Table 1). In contrast, a higher SVI was associated with a lower likelihood of anxiety (OR 0.83, 95% CI 0.70-0.99, p=0.039).

Conclusions: Comorbid depression is more likely among patients with higher social vulnerability, but inequities exist in depression screening with socially vulnerable patients being less likely to be screened. On the other hand, comorbid anxiety was less common among patients with higher social vulnerability, but this may be related to under recognition and inequities in anxiety screening. Awareness of these health inequities, particularly in context of comorbid mental health diagnoses, which are known to influence IBD health and outcomes, is a first step towards efforts to increase screening for comorbid anxiety and depression in socially vulnerable patients with IBD.

Background. It has been reported that up to 50% of patients with inactive inflammatory bowel disease (IBD) have comorbid irritable bowel syndrome (IBS), which is significantly higher than the 4-11% prevalence of IBS in the general population. Studies of IBS/IBD overlap have suggested that these patients have higher healthcare utilization, increased psychological comorbidity, and worse quality of life compared to IBD patients without IBS overlap. Many of the previous studies of IBS/IBD overlap have relied on chart review and patient-reported disease severity scores to identify patients without active IBD. The aim of the current study was to prospectively identify patients with IBS/IBD overlap by evaluating IBS symptoms at the time of colonoscopy.

Methods. Patients seen in the IBD Center at a large academic medical center were invited to participate in this study at the time of colonoscopy. Study participation included completion of surveys to evaluate presence of IBS using Rome IV criteria as well as severity of IBS symptoms using the IBS Severity Scoring System (IBS-SSS). Other survey measures included the Visceral Sensitivity Index (VSI, a measure GI-specific anxiety) and PROMIS measures of constipation, diarrhea, anxiety, depression, and sleep. Chart review identified patients with and without endoscopic disease activity.

Results. 217 patients consented to the study and completed colonoscopy and questionnaires. Of these, 113 (52%) were in endoscopic remission. When defining IBS based on Rome IV criteria, only 8 (7% of the patients without active disease) met full criteria. When defining IBS based on validated IBS-SSS cutoff scores representing “moderate-to-severe” symptoms, 14 (12%) of the sample had IBS-like symptoms. Patients with inactive IBD who reported moderate to severe IBS symptoms were presumed to have IBS for the remaining analyses. Rates of Crohn’s disease, ulcerative colitis, and IBD-unspecified were not significantly different between IBS/IBD, inactive, and active disease. IBS/IBD patients were disproportionately female (86% vs. 44% of inactive IBD, and 49% of active IBD) and reported diarrhea severity that was similar to active IBD and worse than inactive IBD (p<0.001). IBS/IBD also reported higher general anxiety, GI-specific anxiety, and depression scores compared to both active and inactive IBD (Table 1).

Conclusion. In a well-characterized sample of IBD patients in endoscopic remission, IBS prevalence was 7% by Rome IV criteria and 12% using a validated IBS severity cutoff. This is lower than what has been previously reported and is comparable to documented IBS prevalence in the general population. Nonetheless, patients who reported IBS/IBD overlap scored worse on measures of psychological distress compared to active and inactive IBD and reported similar diarrhea severity to those with active IBD.

Introduction: Crohn's disease (CD) is associated with disability by affecting physical and emotional well-being, and by altering social interactions. In the era of treat to target, endoscopic remission has become the therapeutic target to prevent parietal destruction and disability. A deeper remission such as transmural healing would reduce long-term complications related to CD. The impact of transmural healing on disability is currently unknown.
Methods: We conducted a monocentric cross-sectional study between September 2019 and January 2022. Patients followed for CD in endoscopic remission (CDEIS <4) who underwent within < 4 weeks an intestinal ultrasound (IUS) and a disability assessment by an IBD-disk were consecutively included. Four groups were considered: (A) transmural healing defined by the combination of complete endoscopic healing (CDEIS=0) and ultrasound healing (bowel wall thickness (BWT) less than 3 mm), (B) complete endoscopic healing, (C) ultrasound healing and (D) no healing. Moderate to severe disability was defined as an overall score ≥ 40.
Results: A total of 85 patients were included. Forty-four (51.7%) were female, the median age and disease duration were respectively 38 years (interquartile range [IQR], 33-44) and 12.0 years (IQR, 5-20). There was no difference between the four groups in terms of age, sex, BMI, smoking status, disease location or phenotype or number of biologics failure. The median global IBD-Disk score was 25 (IQR, 9-41) and 24 patients (28.2%) had moderate to severe disability. Transmural healing (group A) was observed in 40 patients (47.1%). Moderate to severe disability was identified in 17.5% (7/40) of patients with transmural healing, 25% (4/16) with endoscopic healing, 44.4% (8/18) with ultrasound healing and 45.4 % (5/11) without healing. In univariate analysis, transmural healing reduced the risk of severe disability (group C vs A OR = 3.77, 95% CI [1.10, 13.45], p = 0.035), group D vs A OR = 3 .75, 95% CI [0.91, 17.12], p=0.063). There was no difference in terms of severe disability between patients with transmural healing and complete endoscopic healing (group B versus A OR = 1.57 95% CI [0.36, 6.23], p = 0.525)

Conclusions: Transmural healing did not provide any benefit in terms of disability compared to complete endoscopic healing. Mucosal healing therefore remains the objective to be achieved in order to reduce the risk of short-term disability.

In patients with inflammatory bowel disease (IBD), sexual dysfunction (SD) has been cross-sectionally correlated with depression, disease activity, and poor quality of life. In the present study, we aimed to longitudinally quantify SD with clinical and psychosocial metrics in patients starting biologic therapy.

Patients with Crohn’s disease (CD) or ulcerative colitis (UC) starting new biologic therapy were prospectively surveyed at induction of therapy, 2 months, and at 6 months. Surveys included the IBD-specific Female and Male Sexual Dysfunction Scales (IBD-FSDS and MSDS), PROMIS Brief Sexual Function and Satisfaction Profile, as well as clinical disease activity indices [Harvey-Bradshaw index (HBI), partial Mayo (pMayo) score, Simple Clinical Colitis Activity Index (SCCAI)], scales that assessed depression [Patient Health Questionnaire-9 (PHQ-9)], quality of life [Short IBD Questionnaire (SIBDQ)], and functional disability [IBD-Disability Index (IBDDI)]. Clinical data included Simple Endoscopic and Mayo Scores [(SES), (MES)], inflammatory markers (ESR, CRP, calprotectin) and IBD history. Therapy response was defined as a reduction in HBI, pMayo, SCCAI ≥3 or total HBI ≤ 4, pMayo < 2, SCCAI ≤2 at 6 months.

170 patients (89 males and 81 females) completed surveys at induction, 131 at 2 months, and 112 at 6 months. The median age was 31 years, 59% had CD, 41% had UC, and 30% were non-white. At induction, the median MSDS score was 6 out of 40 (IQR 3-13), FSDS was 13 out of 60 (7-27), PROMIS-male 28 out of 42 (25-34), and PROMIS-female 36.5 out of 62 (32-43) (Table 1). MSDS and FSDS correlated with HBI (r=0.54, 0.63), SIBDQ (0.44, -0.67), IBDDI (0.35, 0.60), PHQ9 (0.33, 0.46) at all 3 time points (p<0.01). PROMIS-Male scores correlated with SCCAI, pMayo, HBI, SIBDQ, IBDDI, PHQ-9 at all 3 time points (p<0.05). PROMIS-female scores also correlated with HBI, SBIDQ, IBDDI, PHQ-9 (p<0.05). SD scores did not correlate with biomarkers of inflammation (ESR, CRP, fecal calprotectin) or endoscopic scores. Among all participants, SD scores significantly improved for both men and women at 6 months, as did disease activity indices, SIBDQ, and IBDDI (Friedman’s test, p<0.001) (Table 2). Participants with a therapeutic response had significant improvement in their SD scores at 6 months (p<0.001), but this was not observed in non-responders.

SD correlated with clinical disease activity indices, but not objective biomarkers of disease activity. There was a strong correlation between SD, depression, disability, and quality of life indices. SD and psychosocial scores improved with biologic therapy, but not in patients who did not respond to therapy. The results of this study further clarify the relationship between SD, disease activity, and therapeutic response in IBD, and suggest that therapy responders are more likely to experience improved sexual functioning.

Baseline patient characteristics, and mean and median sexual dysfunction scores at induction of therapy.

Baseline patient characteristics, and mean and median sexual dysfunction scores at induction of therapy.

Median scores on clinical, psychosocial, and sexual dysfunction scales stratified by therapeutic response. Therapy response was defined as a reduction in HBI, pMayo, SCCAI ≥3 or HBI ≤ 4, pMayo < 2, or SCCAI ≤2 at survey 3. Therapy non-response was defined as a reduction in HBI <3, pMayo <3 points or SCCAI <3. 66% of participants responded to therapy.

Median scores on clinical, psychosocial, and sexual dysfunction scales stratified by therapeutic response. Therapy response was defined as a reduction in HBI, pMayo, SCCAI ≥3 or HBI ≤ 4, pMayo < 2, or SCCAI ≤2 at survey 3. Therapy non-response was defined as a reduction in HBI <3, pMayo <3 points or SCCAI <3. 66% of participants responded to therapy.

Keith Sultan

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