Different clinical outcomes in Crohn’s disease patients with esophagogastroduodenal, jejunal, and proximal ileal disease involvement: is L4 truly a single phenotype?

Ren Mao*, Rui Han Tang, Yun Qiu, Bai Li Chen, Jing Guo, Sheng Hong Zhang, Xue Hua Li, Rui Feng, Yao He, Zi Ping Li, Zhi Rong Zeng, Rami Eliakim, Shomron Ben-Horin, Min Hu Chen

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

15 Scopus citations

Abstract

Background: The Montreal classification defines L4 Crohn’s disease (CD) as any disease location proximal to the terminal ileum, which anatomically includes L4-esophagogastroduodenal (EGD), L4-jejunal, and L4-proximal ileal involvement. L4-jejunal disease was established to be associated with poor prognosis. However, the outcome of patients with L4-proximal ileal disease or L4-EGD remains to be clarified. Our study aimed to investigate whether the outcome differs among CD patients with L4-EGD, L4-jejunal, and L4-proximal ileal disease. Methods: In our retrospective cohort study, 483 patients with confirmed CD were included. The primary outcome was intestinal surgery. Demographic features and outcomes were compared among L4-EGD, L4-jejunal, and L4-proximal ileal disease. Results: Thirty-nine (8.1%) patients had isolated L4 disease, whereas 146 patients had L4 as well as concomitant L1, L2, or L3 disease. During a median follow up of 5.8 years, L4 patients were more likely to have intestinal surgeries compared to non-L4 patients (31% versus 16%, p < 0.001). The percentage of L4-jejunal patients who underwent surgery was higher than that of L4-proximal ileal (66% versus 28%, p < 0.001), and both of these subtypes of L4 were at higher risk for intestinal resection compared to L4-EGD patients (66% and 28% versus 9%, respectively, p < 0.001 and p < 0.05). On multi-variable analysis, L4-jejunal (HR 3.08; 95% CI 1.30–7.31) and L4-proximal ileal disease (HR 1.83; 95% CI 1.07–3.15) were independent predictors for intestinal resection. Conclusions: L4 disease had worse prognosis compared to non-L4 disease. Within L4 disease, phenotype of L4-jejunal and L4-proximal ileal disease indicated higher risk for intestinal surgery. It might be justified to further characterize the L4 phenotype of the Montreal classification into three specific subgroups including L4-EGD, L4-jejunal, and L4-proximal ileal disease, similar to the Paris classification of pediatric patients.

Original languageEnglish
JournalTherapeutic Advances in Gastroenterology
Volume11
DOIs
StatePublished - 1 Jan 2018

Funding

FundersFunder number
National Natural Science Foundation of China81670607, 81500501, 81270473, 81470821
National Natural Science Foundation of China

    Keywords

    • Crohn’s disease
    • Montreal classification
    • proximal ileum
    • surgery

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