title: Do preoperative factors predict subsequent diagnosis of Crohn's disease after ileal pouch-anal anastomosis for ulcerative or indeterminate colitis?
abstract: OBJECTIVE
  The aim of this study was to determine preoperative clinical factors associated with subsequent diagnosis revision to Crohn's disease (CD) following total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) or indeterminate colitis (IC) patients.
  
  
  METHODS
  Presumed UC and IC patients undergoing IPAA from a large single-institution prospective database with change of diagnosis to CD were identified and compared with patients without diagnosis change.
  
  
  RESULTS
  A total of 2814 patients (47% male, median age 37 years) with presumed UC (85%) or IC (15%) underwent primary IPAA. At a median follow up of 9.6 years, 184 (7%) had the diagnosis revised to CD from histopathological examination of the colectomy specimen immediately in 97 (53%) or at a median interval of 36 months in 87 (47%). CD and UC/IC patients had had a similar operative technique, length of stay and 30-day morbidity. The postoperative CD diagnosis was associated with a preoperative diagnosis of IC (P < 0.0001) and perianal fistula (P = 0.002). Patients with a delayed diagnosis of CD were associated with a 3-stage procedure (P < 0.0001, OR = 2.8) (95% CI = 1.8-4.4), colonic stricture (P = 0.04, OR = 2.9 [95% CI = 1.1-7.4]), perianal fistula (P = 0.02, OR = 2.9 [95% CI = 1.2-7.2]), oral ulceration (P = 0.009, OR = 3.8 [95% CI = 1.2-9.6]) and younger age (P < 0.0001, OR = 0.048 [95% CI = 0.011-0.19]).
  
  
  CONCLUSIONS
  A few patients having IPAA for presumed UC/IC were subsequently diagnosed to have CD which was associated with perianal fistula and the diagnosis of postoperative preoperative IC. The delayed diagnosis of CD was associated with a three-stage procedure, colorectal stricture, anal fissure, mouth ulceration and younger age.
authors.affiliation: Digestive Disease Institute, Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
authors.forename: G B
authors.initials: GB
authors.lastname: Melton
authors.forename: R P
authors.initials: RP
authors.lastname: Kiran
authors.forename: V W
authors.initials: VW
authors.lastname: Fazio
authors.forename: J
authors.initials: J
authors.lastname: He
authors.forename: B
authors.initials: B
authors.lastname: Shen
authors.forename: J R
authors.initials: JR
authors.lastname: Goldblum
authors.forename: J-P
authors.initials: JP
authors.lastname: Achkar
authors.forename: Ian C
authors.initials: IC
authors.lastname: Lavery
authors.forename: Feza H
authors.initials: FH
authors.lastname: Remzi
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001003:Anal Canal / Q000601:surgery*; D000714:Anastomosis, Surgical; D016009:Chi-Square Distribution; D002648:Child; D003092:Colitis / Q000150:complications* / Q000601:surgery*; D003093:Colitis, Ulcerative / Q000601:surgery; D039021:Colonic Pouches; D003424:Crohn Disease / Q000175:diagnosis* / Q000209:etiology*; D005260:Female; D006801:Humans; D007082:Ileum / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012307:Risk Factors; D018709:Statistics, Nonparametric