Background Corticosteroids are used for induction of remission in patients with moderately to severely active ulcerative colitis. However, up to one-third of patients fail to this therapy. We investigated if fecal microbial composition or its metabolic capacity are associated with response to systemic corticosteroids. Methods In this prospective, multicenter study, patients with active ulcerative colitis (Lichtiger score ≥4) receiving systemic corticosteroids were eligible. Data were assessed and fecal samples collected before and after 4 weeks of treatment. Patients were divided into responders (decrease of Lichtiger Score ≥50%) and nonresponders. The fecal microbiome was assessed by the 16S rRNA gene marker and analyzed with QIIME 2. Microbial metabolic pathways were predicted using parsimonious flux balance analysis. Results Among 93 included patients, 69 (74%) patients responded to corticosteroids after 4 weeks. At baseline, responders could not be distinguished from nonresponders by microbial diversity and composition, except for a subgroup of biologic-naïve patients. Within 4 weeks of treatment, responders experienced changes in beta diversity with enrichment of ascribed beneficial taxa, including Blautia, Anaerostipes, and Bifidobacterium, as well as an increase in predicted butyrate synthesis. Nonresponders had only minor longitudinal taxonomic changes with a significant increase of Streptococcus salivarius and a microbial composition shifting away from responders. Conclusion Baseline microbial diversity and composition seem to be of limited use to predict response to systemic corticosteroids in active ulcerative colitis. Response is longitudinally associated with restoration of microbial composition and its metabolic capacity.

Background: Among patients with ulcerative colitis, 30–50% receive corticosteroids within the first five years after diagnosis. We aimed to reconsider their effectiveness in the context of the biologic era. Methods: In this prospective, multicenter study, patients with active ulcerative colitis (Lichtiger score ≥ 4) were eligible if initiating systemic corticosteroids. The primary endpoint was clinical response (decrease in the Lichtiger score of ≥50%) at week 4. Secondary endpoints included combined response defined as clinical response and any reduction in elevated biomarkers (CRP and/or calprotectin). Steroid dependence was assessed after three months. Results: A total of 103 patients were included. Clinical response was achieved by 73% of patients, and combined response by 68%. A total of 15% of patients were steroid-dependent. Activity of colitis did not influence short-term response to treatment but increased the risk for steroid dependence. Biologic-naïve patients responded better than biologic-experienced patients. Past smoking history (OR 5.38 [1.71, 20.1], p = 0.003), hemoglobin levels (OR 0.76 [0.57, 0.99] for higher levels, p = 0.045), and biologic experience (OR 3.30 [1.08, 10.6], p = 0.036) were independently associated with nonresponse. Conclusion: Disease activity was not associated with short-term response to systemic corticosteroids but was associated with steroid dependence in patients with active ulcerative colitis. Exposure to biologics negatively affects response rates.

Hintergrund und Ziele Systemischen Kortikosteroide sind eine wichtige Substanzgruppe in der Behandlung der aktiven Colitis ulcerosa (CU). Das Ansprechen auf medikamentöse Therapien wie Biologika wird mutmaßlich durch das Darmmikrobiom beeinflusst. Wir untersuchten ob die Zusammensetzung und die Funktion des Mikrobioms bei Patienten mit aktiver CU auch in Zusammenhang mit dem Therapieansprechen auf Kortikosteroide steht.

Background Little is known about the bleeding risk in patients with inflammatory bowel disease (IBD) and venous thromboembolism (VTE) treated with anticoagulation. Our aim was to elucidate the rate of major bleeding (MB) events in a well-defined cohort of patients with IBD during anticoagulation after VTE. Methods This study is a retrospective follow-up analysis of a multicenter cohort study investigating the incidence and recurrence rate of VTE in IBD. Data on MB and IBD- and VTE-related parameters were collected via telephone interview and chart review. The objective of the study was to evaluate the impact of anticoagulation for VTE on the risk of MB by comparing time periods with anticoagulation vs those without anticoagulation. A random-effects Poisson regression model was used. Results We included 107 patients (52 women, 40 with ulcerative colitis, 64 with Crohn disease, and 3 with unclassified IBD) in the study. The overall observation time was 388 patient-years with and 1445 patient-years without anticoagulation. In total, 23 MB events were registered in 21 patients, among whom 13 MB events occurred without anticoagulation and 10 occurred with anticoagulation. No fatal bleeding during anticoagulation was registered. The incidence rate for MB events was 2.6/100 patient-years during periods exposed to anticoagulation and 0.9/100 patient-years during the unexposed time. Exposure to anticoagulation (adjusted incidence rate ratio, 3.7; 95% confidence interval, 1.5-9.0; P = 0.003) and ulcerative colitis (adjusted incidence rate ratio, 3.5; 95% confidence interval, 1.5-8.1; P = 0.003) were independent risk factors for MB events. Conclusion The risk of major but not fatal bleeding is increased in patients with IBD during anticoagulation. Our findings indicate that this risk may be outweighed by the high VTE recurrence rate in patients with IBD.

Background and aims Corticosteroids are still widely used to treat flares of ulcerative colitis (UC) but steroid-refractory UC has been reported in 24-33 % of patients in historic cohorts. This study aimed to assess factors influencing efficacy of corticosteroid therapy for active UC in the biologic era.

AbstractIntroductionPatients with inflammatory bowel disease (IBD) suffer from various symptoms, impairing their quality of life and often affecting psychosocial issues. This may lead to the need for additional psychological care. This study investigated patients' subjective need for integrated psychosomatic support and psychotherapy and indicators for it.Materials and methodsThis is a cross‐sectional multicentre study in Austrian IBD patients who were in routine care at 18 IBD outpatient clinics. Patients filled in an anonymous, validated questionnaire (Assessment of the Demand for Additional Psychological Treatment Questionnaire [ADAPT]) assessing the need for psychological care. The ADAPT gives two separate scores: the need for integrated psychosomatic support and for psychotherapy. In addition, health‐related quality of life and the use of complementary and alternative medicine as well as clinical and socio‐demographic variables were queried. Multivariable regression analysis was performed to estimate the effect of the previously mentioned variables on the need for additional psychological care.ResultsOf 1286 patients, 29.7% expressed a need for additional psychological care, 19.6% expressed a need for integrated psychosomatic support and 20.2% expressed a need for psychotherapy. In the multivariable analysis, the two strongest indicators for the need for both types of psychological care were the use of complementary and alternative medicine (for integrated psychosomatic support: odds ratio = 1.64, 95% confidence interval 1.13–2.39, p = 0.010; for psychotherapy: odds ratio = 1.74, 95% confidence interval 1.20–2.53, p = 0.004), and a low health‐related quality of life score (for integrated psychosomatic support: odds ratio = 0.95, 95% confidence interval 0.94–0.96, p < 0.001; for psychotherapy: odds ratio = 0.96, 95% confidence interval 0.94–0.97, p < 0.001).DiscussionAbout 30% of the Austrian IBD patients expressed a need for integrated psychosomatic support and/or psychotherapy. The most important indicators for this need were the use of complementary and alternative medicine and low quality of life.

A 20-year old man of Balkan descent presented to the emergency department with abdominal pain and constipation of several days‘ duration. On clinical examination, he was afebrile and normotensive. The abdomen was distended with reduced bowel sounds. Laboratory investigations were significant for hyponatraemia (129 mmol/l) and elevated aminotransferases in the double digits; inflammatory markers were normal. Abdominal ultrasound was unrevealing as to a specific cause but meteorism was noted. Cortisol response to an adrenocorticotrophic hormone stimulation test was normal. It transpired that the patient‘s father suffered from an unusual disease involving the gastrointestinal tract, more specific details could not be obtained at that time due to a language barrier. As symptoms worsened over the next days, computed tomography (CT) of the abdomen was performed, demonstrating marked and diffuse intestinal distension (Fig. 1A and B). A laboratory analysis revealed the cause.

Abstract Background inflammatory bowel diseases (IBD) are lifelong conditions challenging the patient not only with respect to somatic complaints but also affecting psychosocial issues. This may lead to the need for additional psychological care. The present study investigated the patients’ subjective need for additional psychological care and indicators for such a need. Methods We performed a cross-sectional multicentre study on Austrian IBD patients who were in routine care at one of the 18 participating IBD centres. The patients were asked to fill in a questionnaire booklet including the ADAPT, a validated questionnaire on the need for psychological care which gives two separate scores (‘ADAPT-IPC’ -need for integrated psychosomatic care, ‘ADAPT-PT’- need for psychotherapy), a validated questionnaire on the use of complementary and alternative medicine (CAM), the SIBDQ, and questions on clinical and sociodemographic data. The primary endpoint was the need for integrated psychosomatic care, psychotherapy or both. Results 1286 patients returned the questionnaire. In total, 29.7% of all patients expressed a need for additional psychological care, 18.6% expressed a need for ADAPT-IPC and 20.2% expressed a need for ADAPT-PT. The multivariable regression analysis revealed the two dominating factors associated with the need for both types of psychological care were the use of CAM and a low SIBDQ-score ≤ 50 (see Table for details). Conclusion About 30% of the Austrian IBD patients expressed a need for integrated psychosomatic therapy a/o psychotherapy. This need was especially associated with reduced quality of life and the use of CAM which may indicate the desire for emphathetic and dedicated care. Further studies will be necessary to clarify if these results can be reproduced in other countries.

Objective Complementary and alternative medicine (CAM) seems to be frequently used among patients with inflammatory bowel disease (IBD). We aimed to determine the prevalence and indicators of CAM use in Austrian IBD patients. Methods In a multicentre cross-sectional study, adult patients with IBD attending 18 Austrian outpatient clinics completed a multi-item questionnaire that recorded use of CAM as well as medical and socioeconomic characteristics. Patients were recruited between June 2014 and June 2015. The study outcome was the prevalence of CAM use and its socioeconomic and disease-related associations. Results A total of 1286 patients (Crohn’s disease 830, ulcerative colitis 435, IBD unclassified 21; females 651) with a median age of 40 years (interquartile range 31–52 years) and a median disease duration of 10 years (4–18 years) were analysed. The prevalence of previous and/or current CAM use was 50.7%, with similar results for Crohn’s disease and ulcerative colitis. In the multivariable analysis, female gender and a university education were independent socioeconomic indicators of CAM use. IBD-related indicators were longer duration of the disease and previous and/or current treatment with steroids and TNF-α inhibitors. Conclusion CAM use for IBD is frequent in Austrian IBD patients and associated with female gender, higher educational level of university degree, longer duration of the disease, and treatment with steroids and TNF-α inhibitors.

Delayed diagnosis seems to be common in inflammatory bowel diseases (IBD). The study was carried out to investigate the diagnostic delay and associated risk factors in Austrian IBD patients.

ZusammenfasungAnti-TNF-α-Antikörper haben die Therapie chronisch-entzündlicher Darmerkrankungen und anderer immunmediierter inflammatorischer Erkrankungen revolutioniert. Der zunehmende Einsatz dieser Substanzen war Anlass, den Konsensusbericht zur sicheren Anwendung von Infliximab der Arbeitsgruppe für Chronisch Entzündliche Darmerkrankungen der Österreichischen Gesellschaft für Gastroenterologie und Hepatologie aus dem Jahr 2010 zu aktualisieren und auf alle anti-TNF-α-Antikörper zu erweitern. Der vorliegende Konsensusbericht fasst die aktuelle Datenlage zur sicheren Anwendung von anti-TNF-α-Antikörpern zusammen und berücksichtigt folgende Themen: allgemeines Infektionsrisiko, bakterielle Infekte (inkl. Clostridium difficile, Tuberkulose, Nahrungsmittelhygiene), Pneumozystis jiroveci, virale Infektionen (inkl. Hepatitis B, Hepatitis C, HIV, CMV, VZV), Impfungen und Impfempfehlungen, gastrointestinale Aspekte (perianale Fistel, abdominale Fistel, Stenose), dermatologische Aspekte (Haut-Malignome, Ekzem-ähnliche anti-TNF-α-assoziierte Hautläsionen), Infusionsreaktionen und Immunogenität, demyelinisierende Erkrankungen, Hepatotoxizität, Hämatotoxizität, Herzinsuffizienz, Malignomrisiko und Einsatz nach Malignomen, sowie Schwangerschaft und Stillen. Da der Konsensusbericht als praktischer Leitfaden für die sichere Anwendung dieser Substanzen dienen soll, wurden die relevanten Aspekte in einer Checkliste zusammengefasst, die sich in zwei Teile „vor Therapie“ und „während Therapie“ gliedert.

Long diagnostic delay is frequent in inflammatory bowel disease and has been described to be associated with an increased risk for intestinal surgery in patients with Crohn’s disease. We sought to investigate the effect of diagnostic delay on the risk of surgery in patients with ulcerative colitis (UC). In a multicentre cohort study adult patients with UC attending 18 Austrian outpatient clinics were recruited between May 2014 and July 2015 to complete a multi-item questionnaire recording medical characteristics including diagnostic delay. Diagnostic delay was defined as the time period from the first symptom onset to diagnosis of UC. Patients without surgery were compared with those who had undergone colectomy. The survey preparation, data capturing, and exploratory data analysis were performed by using EvaSys software and SPSS. 400 patients with UC (192 females) were analysed. The median age at diagnosis was 28 years (IQR 22–41 years) and the median duration of disease was 8 years (IQR 3–16 years). 22 patients (12 females) had undergone colectomy. The median diagnostic delay in UC patients with surgery was significantly shorter than in patients without surgery (median 0.19 years (IQR 0.03–0.28 years) vs. median 0.28 years (IQR 0.19–0.87 years); p < 0.0001). The probability to be diagnosed with UC after first symptom onset is given in Figure 1. Patients with surgery had a longer duration of disease (median 18 years (IQR 10–27 years) vs. median 8 years (IQR 3–15 years; p < 0.0001). Time to diagnosis of UC (years) by colectomy during the further course of the disease In this large Austrian referral centre based UC cohort a short diagnostic delay was associated with a higher risk of colectomy. This might reflect disease severity at the time of disease onset and the subsequent course of disease.

Patients with inflammatory bowel disease (IBD) are at increased risk of first and recurrent venous thromboembolism (VTE). Anticoagulation (AC) is the standard treatment of VTE, but might lead to bleeding complications. We sought to investigate if the bleeding rate is increased during episodes with AC in patients with IBD and VTE. In a previous study 157 IBD patients with objectively diagnosed VTE were identified. From these patients 107 were included in the analysis. Data were recorded from the medical records and by interviewing the patients via a phone call. The primary end point was the occurrence of a severe bleeding complication, which was defined as a fatal bleeding or a symptomatic bleeding in a critical organ (e.g. intracerebral bleeding) or a bleeding leading to a loss of haemoglobin of ≥20 g l−1or leading to a transfusion of ≥2 red cell packages (RCP). The study is a sequential therapy comparison, in which the bleeding rate in the same patient during episodes under and without AC was compared. Patients contributed episodes with and without AC with variable length. The unit of analysis was each episode. To allow for this longitudinal data structure we used regression models with weighting for the length of each separate episode and based the calculation of 95% confidence intervals and p-values on cluster robust standard errors with patients ID as the identifier. Anticoagulation yes vs. no was the main covariate. For binary outcomes we used logistic models , otherwise we used linear models. To adjust for other clinically predetermined influential variables we used multivariable regression models. A total of 195 episodes without AC and 144 episodes under AC were observed. 21 major bleedings occurred. 10 under AC (5 under heparin and 5 under vitamin-K antagonist treatment) (8: transfusion of ≥2 RCP; 2: loss of haemoglobin of ≥ 20 g l-1) and 11 without AC (8: transfusion of ≥2 RCP; 2: loss of haemoglobin of ≥20 g l-1; 1: death) (Table 1). Major bleeding complications did not occur more often in time periods under AC than in time periods without AC using Fisher’s exact test (p = 0.65). This was confirmed by logistic regression (Table 2). Number of major bleeding complications in time periods under and without anticoagulation treatment (AC). Number of major bleeding complications in time periods under and without anticoagulation treatment (AC). Logistic regression for major bleeding complications. Logistic regression for major bleeding complications. Our data suggest that anticoagulant treatment after VTE does not increase the risk of major bleeding complications in patients with IBD.

Anti-TNFα-antibodies have revolutionized the therapy of inflammatory bowel diseases and other immune-mediated inflammatory diseases. Due to the increasing application of these substances, the Working Group of Inflammatory Bowel Diseases of the Austrian Association of Gastroenterology and Hepatology intended to update their consensus report on the safe use of Infliximab (published in 2010) and to enlarge its scope to cover all anti-TNFα-antibodies. The present consensus report summarizes the current evidence on the safe use of anti-TNFα-antibodies and covers the following topics: general risk of infection, bacterial infections (i. e., Clostridium difficile, Tuberculosis, food hygiene), Pneumocystis jiroveci, viral infections (i. e., Hepatitis B, Hepatitis C, HIV, CMV, VZV), vaccination in general and recommendation for vaccines, gastrointestinal aspects (i. e., perianal fistula, abdominal fistula, intestinal strictures, stenosis and bowel obstruction), dermatologic aspects (skin malignancies, eczema-like drug-related skin eruption), infusion reactions and immunogenicity, demyelinating diseases, hepatotoxicity, haematotoxicity, congestive heart failure, risk and history of malignancies, and pregnancy and breast feeding. For practical reasons, the relevant aspects are summarized in a checklist which is divided into two parts: issues to be addressed before therapy and issues to be addressed during therapy.

Objectives: We report on a large prospective, multicentre clinical investigation on inter-and intrapatient genetic variability for antimicrobial resistance of Helicobacter pylori. Methods: Therapy-naive patients (n = 2004) who had undergone routine diagnostic gastroscopy were prospectively included from all geographic regions of Austria. Gastric biopsy samples were collected separately from antrum and corpus. Samples were analysed by histopathology and real-time PCR for genotypic resistance to clarithromycin and quinolones. Clinical and demographic information was analysed in relation to resistance patterns. Results: H. pylori infection was detected in 514 (26%) of 2004 patients by histopathology and confirmed in 465 (90%) of 514 patients by real-time PCR. PCR results were discordant for antrum and corpus in 27 (5%) of 514 patients, indicating inhomogeneous infections. Clarithromycin resistance rates were 17% (77/ 448) and 19% (84/455), and quinolone resistance rates were 12% (37/310) and 10% (32/334) in antrum and corpus samples, respectively. Combination of test results per patient yielded resistance rates of 21% (98/465) and 13% (50/383) for clarithromycin and quinolones, respectively. Overall, infection with both sensitive and resistant H. pylori was detected in 65 (14%) of 465 patients. Conclusions: Anatomically inhomogeneous infection with different, multiple H. pylori strains is common. Prospective clinical study design, collection of samples from multiple sites and microbiologic methods that allow the detection of coinfections are mandatory for collection of reliable data on antimicrobial resistance patterns in representative patient populations. (ClinicalT02122,98 identifier: NCT02925091). C. Bilgilier, Clin Microbiol Infect 2018;24:267. (C) 2017 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

We conducted a large prospective, multicenter clinical investigation on the antimicrobial resistance of H. pylori strains against clarithromycin and quinolones in Austria.

Background: Long diagnostic delay is frequent in inflammatory bowel disease (IBD), especially in Crohn's disease (CD), and may lead to irreversible bowel damage. We sought to investigate the diagnostic delay in a large cohort of Austrian IBD patients. Methods: In a multicentre cohort study adult patients with IBD (Crohn's disease CD, ulcerative colitis UC, inflammatory bowel disease unclassified IBDU) attending 18 Austrian outpatient clinics were recruited between May 2014 and July 2015 to complete a multi-item questionnaire. Medical and socioeconomic chararteristics including diagnostic delay were recorded by that questionnaire. Diagnostic delay was defined as the time period from the first symptom onset to diagnosis of IBD. The survey preparation, data capturing and exploraratory data analysis were performed by using EvaSys software and SPSS. Results: 1218 patients (792 with CD, 405 with UC, 21 with IBDU; 617 women) with a mean age at the time of investigation of 41.5 years (range 18–87 years) and a mean duration of disease of 12.4 years (range 0–49 years) were analyzed. Patients with IBDU were included in the UC group. The median diagnostic delay in patients with CD was 0.53 years (95% confidence interval (CI) 0.45–0.61 years) and in patients with UC/IBDU was 0.28 years (95% CI 0.28–0.36 years) (p<0.001). The probability to be diagnosed with IBD after first symptom onset is given in Figure 1. Figure 1. Time to diagnosis by type of disease. Conclusions: In this large Austrian referral center based IBD cohort the diagnostic delay was significantly longer in CD than in UC/IBDU. The median diagnostic delay was 6 months in CD patients and 3 months in UC/IBDU patients.

Background: CAM is frequently used in Western European countries, especially in chronic diseases such as inflammatory bowel diseases (IBD), with a frequency ranging from 20% to 50%. No recent data on CAM use are available for Austrian IBD patients. The aim of our study is to determine the frequency of CAM use in IBD patients in Austria as well as factors influencing CAM use.

Results: A total of 383 IBD patients [ulcerative colitis (UC):151; Crohn's disease (CD):225, and IBD-U:7] were tested for CDI during the study period.CDI was detected in 28 (7.3%) patients (7.3% UC; 7.6% CD).The mean age of patients with or without CDI was comparable (46 ± 21 vs. 44 ± 20 years, respectively).Patients with CDI were more frequently hospitalized during the 2 months prior to CDI (71% vs 29%, P<0.05), they were more likely to be treated by systemic steroids (50% vs 24%, P<0.05) and by proton pump inhibitors (54% vs 21%, P<0.05).Patients with or without CDI had similar mean hospitalization duration (7.1 days), and there was no significant difference in mortality and in the number of subsequent hospitalizations during the year following CDI was noticed.Conclusions: The rate of CDI in patients hospitalized due to IBD exacerbation is 7.3%, higher than the reported CDI rate of the general population.However, CDI may not impact patients' prognosis as previously thought.

Patients with ulcerative colitis and Crohn's colitis are at increased risk of colorectal cancer (CRC). This risk is dependent on the duration and extent of disease, inflammatory activity and possible additional risk factors. Thus, the aim is to reduce this risk and to detect dysplastic and malignant lesions at an early stage. The working group for Inflammatory Bowel Diseases (IBD) of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) has developed consensus statements on the following topics: risk of colorectal cancer, screening and surveillance, procedure of surveillance colonoscopy, dysplasia and its management, and chemoprevention. This consensus is intended to increase awareness of the increased risk of CRC in IBD and to support a standardised approach in cancer prevention.