Patients with Crohn's Disease and Bowel Obstruction Have Higher Prevalence of Sinus Disorders

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Contact: Kenneth Satterfield561-447-5521 (May 9-14, 2002)703-519-1563[email protected]

Patients with Crohn's Disease and Bowel Obstruction Have Higher Prevalence of Sinus Disorders

Boca Raton, FL -- Inflammatory bowel disease (IBD) consists of a group of chronic inflammatory disorders involving the gastrointestinal tract and typically is divided into two major disorders: Crohn's disease (CD) and ulcerative colitis (UC). Crohn's disease is characterized by noncontiguous chronic inflammation, often transmural with noncaseating granuloma formation. It can involve any portion of the alimentary tract, and Crohn's inflammation has been described in the nose, mouth, larynx, and esophagus in addition to the more common small bowel and colon sites. Ulcerative colitis differs from Crohn's disease in that it is characterized by contiguous chronic inflammation without transmural involvement (but extraintestinal manifestations of UC have also been described).

Although nasal manifestations of these disorders have been described, there are no reports of an association between inflammatory bowel disease and chronic sinonasal disease. This study was undertaken to determine the prevalence of chronic sinus or nasal disorders in an IBD patient population. The authors of "Chronic Sinonasal Disease in Patients with Inflammatory Bowel Disease," are David T. Book MD, Timothy L. Smith, MD MPH, Justin P. McNamar, Kia Saeian MD, David G. Binion, MD, and Robert J. Toohill MD, all from the Medical College of Wisconsin, Milwaukee, WI. Their findings will be presented May 10, 2002, at the Annual Meeting of the American Rhinologic Society http://www.american-rhinologic.org/, at the Boca Raton Resort & Club, Boca Raton, FL.

Methodology: The charts of all patients with suspected IBD followed in a tertiary gastroenterology clinic were reviewed. For inclusion in the study, patients were required to have a gastroenterologist's diagnosis with colonoscopy and biopsy specimens consistent with ulcerative colitis or Crohn's disease. The study protocol included a chart review of the patient population and a survey mailed to eligible subjects.

The chart review collected information on each of the patient's IBD diagnosis, history of bowel obstruction secondary to IBD, and nasal or sinus disease reported. Then an additional survey containing specific questions related to the presence of sinonasal disease or symptoms was developed and mailed to all eligible patients to further identify the presence of nasal and sinus disease.

The follow-on survey assessed the presence of chronic sinus and nasal disease based on a history of prior diagnosis, questions regarding sinonasal symptoms, and history of treatment modalities, including both pharmacologic and surgical interventions. Survey recipients were asked about sinus infections, congestion, and nasal breathing difficulty lasting greater than three months and symptoms such as nasal drainage, frequent colds with associated headaches or facial pain, persistent facial pain without upper respiratory infection, olfaction, and the use of antibiotics. They were asked about airborne/environmental allergies and sinonasal symptoms associated with weather changes, tobacco smoke, or changes in the seasons. Patients were also queried about their history of previous evaluation or diagnosis by a physician of acute or chronic rhinitis, acute or chronic rhinosinusitis, history of sinus x-rays or CT scans, nasal or sinus surgery, and the use of pharmacologic agents for nasal or sinus symptoms.

Patients returning the survey were categorized into three groups based on their IBD history: 1) ulcerative colitis, 2) Crohn's disease with history of obstructive symptoms (bowel obstruction), and 3) Crohn's disease without history of bowel obstruction. Chronic sinonasal symptoms were categorized as those diagnosed by a physician as having chronic rhinitis, chronic sinusitis, or patients with chronic sinonasal symptoms but lacking a formal diagnosis.

Patients were defined as having chronic symptoms if they had one major and two minor factors regarding persistent sinonasal congestion or infections for greater than three months duration. If respondents answered "yes" to three or more of the questions regarding nasal and sinus symptoms for greater than three months, they were also considered to have chronic symptoms. The Chi-squared test was used to compare differences between prevalence of sinonasal disease and symptoms between groups.

Results: Two hundred eighty patients with suspected IBD were initially evaluated for inclusion. Of these, 241 patients were eligible for the study and were sent surveys. One hundred sixty (66.4 percent) surveys were returned and included in data analysis. Findings were:

* Forty-four of the respondents (27.5 percent) had the diagnosis of UC. In this group there were 20 men and 24 women with a mean age of 43.7 years. One hundred sixteen (72.5 percent) patients reported a diagnosis of CD, with 75/116 (64.7 percent) reporting a history of bowel obstruction. The mean age for this subset was 40.2 years and included 35 men and 40 women. The remaining 40 patients (34.5 percent) with CD included 21 men and 19 women with a mean age of 45.2 years and no history of bowel obstruction.

* In total 47.5 percent (76/160) of patients with IBD reported a history of chronic rhinosinusitis, chronic rhinitis, or chronic sinonasal symptoms. Chronic rhinosinusitis was reported by 24/160 (15.0 percent), chronic rhinitis by 15/160 (9.4 percent), and chronic sinonasal symptoms by 37/160 (23.1 percent).

* Among the survey respondents with CD and a history of small or large bowel obstruction, 17/75 (22.7 percent) had a diagnosis of chronic rhinosinusitis, whereas only three of 41 (7.3 percent) of those CD patients without obstruction had chronic rhinosinusitis. Of the 17 patients in the first group, 10 (58.8 percent) also had a history of allergies; 15 (88.2 percent) had received medical therapy for their sinusitis; and six (35.3 percent) had undergone nasal or sinus surgery. Ten (13.3 percent) CD with obstruction patients had a diagnosis of chronic rhinitis associated with allergies; 24 (32.0 percent) reported a history of chronic sinonasal symptoms, and 24 (32.0 percent) responded that they had no nasal or sinus problems. Forty patients (53.3 percent) in this subgroup reported a history of environmental or seasonal allergies.

* In total 51/75 (68.0 percent) of patients with CD with bowel obstruction also had chronic sinonasal complaints or disease. Among the cohort of patients with CD without a history of bowel obstruction, 4/41 (9.8 percent) reported a history of chronic rhinitis, 4/41 (9.8 percent) chronic sinonasal symptoms, and 30/41 (73.2 percent) had no sinonasal disease. Twelve (29.3 percent) reported a history of allergies.

Conclusions: A high prevalence of chronic rhinosinusitis and chronic sinonasal disorders exists in Crohn's disease patients with a history of obstructive bowel symptoms. While the cause for this association remains unclear, several pathophysiologic mechanisms may play a role, potentially involving altered motility or chronic small intestinal, as opposed to colonic inflammation. The researchers believe that further investigation is required to define the specific mechanisms underlying chronic sinonasal disease in CD patients with small bowel inflammation and obstructive presentations.

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