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ICN Travel Toolkit -Tips for Patients with Inflammatory Bowel Disease

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ImproveCareNow’s Patient Advisory Committee: ICN Travel Toolkit – a collection of personal stories, plus tips and techniques for traveling with IBD – written by members of the ICN Patient Advisory Council (PAC).

In addition to the tips offered by the PAC (see below), I would recommend that those travelling keep a succinct medical summary with the following (minimum):

  • Diagnosis and extent of disease
  • Other medical problems
  • Physician (contact info)
  • Allergies –food/medicines
  • Current list of medications including dosage and frequency
  • List of prior treatments
  • Previous surgeries

Also, below are other travel -related links, including to the CDC travel website which makes recommendations based on travel destination along with underlying problems.

A summary of the ICN travel tips from the PAC PowerPoint Presentation:

 

 

Fluid Management for Abdominal Surgery

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A recent study (PS Myles et al. NEJM 2018; 378: 2263-74, editorial 2335-6) throws some shade on the idea that restricting IV fluids during surgery results in better outcomes.

With ERAS (enhanced recovery after surgery) procedures, one of the components has been restricting IV fluids during surgery due to concerns that excessive fluid will result in bowel wall edema and slower recovery.  To better determine if a restrictive IV fluid approach or a more liberal approach was better, this RELIEF study randomized approximately 3000 patients who were receiving major abdominal surgery into two arms: a restrictive group and a  liberal group; they received a median of 3.7 liters of IV fluids and 6.1 liters respectively during and up to 24 hours after surgery.

Key findings:

  • Rate of disability-free survival at 1 year was 81.9% in the restrictive group and 82.3% in the liberal group (hazard ratio for death or disability was 1.05, CI 0.88-1.24, P=0.61)
  • Rate of acute kidney injury was 8.6% in the restrictive fluid group compared to 5.0% in the liberal fluid group (P<0.001). Renal replacement therapy was 0.9% in the restrictive fluid group compared to 0.3% in the liberal fluid group (P=0.048).
  • Rates of surgical site infection was 16.5% in the restrictive fluid group compared to 13.6% in the liberal fluid group (P=0.02).  The authors speculate that this could be related to perfusion of surgical anastomosis.

The associated commentary notes that in this age of minimally invasive surgery, a modestly liberal administration of IV fluids does not create substantial fluid retention.

My take: Restrictive fluid regimen during major abdominal surgery resulted in higher rates of kidney injury and surgical site infections.  This study indicates that for ‘enhanced recovery’ that a more liberal fluid regimen is safer.

Related posts:

 

 

Pediatric Intestinal Pseudo-obstruction: Consensus Recommendations

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A new report from an ESPGHAN-Led Expert Group (N Thapar et al. JPGN 2018; 66: 9991-1019) provides detailed recommendations for pediatric intestinal pseudo-obstruction (PIPO).  In addition, this report serves as an excellent self-assessment of your vision.  If you can read figure 1, which has some incredibly tiny font size, then your vision is fantastic.

Full Link: “Paediatric Intestinal Pseudo-obstruction: Evidence and Consensus-based Recommendations From an ESPGHAN -Led Expert Group”

Aside from that snarky comment, the report offers a great deal of useful advice.

  • After obstruction has been excluded, the authors recommend that patients should undergo a basic laboratory evaluation (including CBC, CMP, ESR/CRP, Celiac serology, Cortisol, Thyroid testing, Metabolic tests [urine organic acids, ammonia, lactate]) and to consider more extensive evaluation.
  • If primary, rather than secondary, PIPO is suspected, the authors recommend neurogastroenterology evaluation.

Subsequently, the authors review management: potential medications (Table 6), enteral feeds, gastrostomy and ileostomy, and in more than 80% then need for parenteral nutrition. At the time of therapeutic procedures, it is recommended to obtain full-thickness biopsies to further characterize the PIPO.

Clinical features which distinguish pediatric chronic intestinal pseudo-obstruction (CIPO) from adult CIPO are listed in Table 2. These include the following:

  • Frequent urologic involvement in pediatric CIPO which is rare in adults with CIPO.
  • Dilated bowel loops are commonly absent (~40%) in pediatric CIPO in the neonatal period and universal in adult cases.
  • Unlike in adults, there is a high risk of colonic and small bowel volvulus in pediatric CIPO and malrotation is evident in ~30% of pediatric CIPO (rarely seen in adults).
  • Also, in pediatrics, fabricated cases are more commonly encountered.

Intestinal transplantation should be considered in patients with PIPO who develop life-threatening complications associated with TPN or poor quality of life/high morbidity.

Pictures below from yesterday’s Peachtree Road Race and previous T-shirts from previous years.

 

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Why Does this Patient Have Colitis?

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Just in time for this year’s Peachtree Road Race…

A brief report (RS Robinson et al. Gastroenterol 2018; 154: 1582-83) presents a case of a 28 year old, who had been in training for a marathon, with mild iron deficiency anemia, lower abdominal pain, and bloody bowel movements. The CT scan and colonoscopy showed diffuse colonic/ileal inflammation; the histology showed mucosal necrosis, crypt atrophy and acute inflammation (see below).

Answer to title question: Runner’s Colitis.  The authors note that in some long-distance runners an ischemic colitis can develop in part due to rerouting of blood with prolonged exercise.  Dehydration may exacerbate poor perfusion.  The splenic flexure and the rectosigmoid junction are particularly susceptible due to the ‘watershed’ nature of their blood supply.

The majority of individuals recover fully from this insult, though the literature describes one individual who required a subtotal colectomy after perforation.

VICTORY Consortium Showing Good Results for Vedolizumab

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A presentation at the 13th Congress of the European Crohn’s and Colitis Organization (ECCO, Feb 2018) indicated that Vedolizumab had similar effectiveness as anti-TNF agents for both ulcerative colitis and Crohn’s disease. This data has been presented at a recent meeting in our office, some of the GI news magazines, and also ImproveCareNow listserv.

From Takeda website: Entyvio® (vedolizumab) Shows Higher Rates of Mucosal Healing Versus TNFα-Antagonist Therapy in Ulcerative Colitis and Crohn’s Disease Patients in Comparative Effectiveness Real-World Data Analysis

These analyses observed that patients with UC treated with Entyvio compared to TNFα-antagonist therapy had statistically significant higher 12-month cumulative rates of mucosal healing (50% vs 42%, hazard ratio [HR] 1.73, 95% confidence interval [CI] 1.10‑2.73) and clinical remission (54% vs 37%; HR 1.54, 95% CI 1.08‑2.18), and numerically higher steroid-free clinical remission rates (49% vs 38%; HR 1.43, 95% CI 0.79‑2.60). In CD, results reported statistically significant higher 12-month cumulative rates of mucosal healing (50% vs 41%; HR 1.67, 95% CI 1.13‑2.47), and numerically higher rates of clinical remission (38% vs 34%; HR 1.27, 95% CI 0.91‑1.78) and steroid-free clinical remission (26% vs 18%; HR 1.75, 95% CI 0.90‑3.43) compared to TNFα-antagonist therapy. These analyses were conducted by the VICTORY (Vedolizumab Health OuTComes in InflammatORY Bowel Diseases) Consortium.

My take: While the data compare anti-TNFs to vedolizumab in a “real-world setting,” the reported outcomes for anti-TNFs are lower than in other studies.  Vedolizumab had the best results in those with colonic disease.  Patients with Crohn’s disease with isolated small bowel disease had lower response rates.

Related study: AK Waljee et al Inflamm Bowel Dis 2018; 24: 1185-95. Using phase 3 clinical trial data with 594 subjects, the authors note that the majority of patients who will respond to vedolizumab can be identified by week 6 using a laboratory algorithm based on hemoglobin, albumin, vedolizumab level and CRP. Fformula: Hgb*Albumin*VDZ level/CRP*Weight. A cutoff of 185.96 predicted success with an AuROC of 0.75.   Higher hemoglobin, higher albumin, and higher vedolizumab level, and lower CRP are associate with higher response rates.

Related blog posts:

Red Top Mountain, Homestead Trail

 

 

 

What to Make of Median Arcuate Ligament Syndrome

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A recent study (C Stiles-Shields et al. JPGN 2018; 66: 71) reports on 32 cases of median arcuate ligament syndrome (MALS) from a single center, 2011-17.  To me, this is an astounding number of individuals who were operated on for this disorder.  As the authors note, “MALS remains a controversial and vexing condition. 13% to 50% of healthy patients may exhibit radiographic features of celiac artery compression.”

While the authors note that pain symptoms improved significantly, they report that “comorbid psychological conditions were common, occurring in about half the sample before and after surgery.”

My take: If one finds celiac artery compression and suspects MALS, it is unclear to me if an operation is indicated and how to determine when it is indicated.

Related blog post:

Proctor Creek Trail

Which Proton Pump Inhibitor is the Most Potent?

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A recent study (DY Graham, A Tansel. Clin Gastroenterol Hepatol 2018; 16: 800-808) analyzed 56 randomized trials to determine relative potency of proton pump inhibitors (PPIs) based on time in which intragastric pH was 4 or less (pH4time).

Key findings:

  • Pantoprazole 20 mg was equivalent to 4.5 mg of omeprazole
  • Lansoprazole 15 mg was equivalent to 13.5 mg of omeprazole
  • Esomeprazole 20 mg was equivalent to 32 mg of omeprazole
  • Rabeprazole 20 mg was equivalent to 36 mg of omeprazole

The authors note that peak effectiveness for PPIs was at ‘approximately 70 mg of omeprazole equivalents’.  In addition, they state that twice a day dosing was more effective than increasing once a day dosing; however, three times a day dosing was not more effective than twice a day. “Dexlansoprazole, a quasi-twice-a-day formulation produced similar acid suppression to the lowest twice-daily PPI regimen and 20 mg vonoprazan once daily provided similar efficacy aas high-dose twice-daily PPI.” The authors also compare costs; generics of pantoprazole, omeprazole, and esomeprazole cost as little as $0.02-0.04 per omeprazole equivalent.  Thus, 20 mg of omeprazole would be as little as 40 cents.

My take: Using the lowest effective dose of a PPI is recommended.  In patients needing higher dosing or with suboptimal response to acid suppression, this data can be very helpful.

 

Proctor Creek Trail

IBD Shorts June 2018

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AL Granstrom et al. JPGN 2018; 66: 398-401. Using a nationwide Swedish registry, the authors determined that patients with a Hirschsprung disease had an increased risk of receiving a diagnosis of IBD (OR 4.99).  In total 20 of 739 HD patients, developed IBD.

T Card et al. Inflamm Bowel Dis 2018; 24: 953-9.  This article questions the ‘what is the risk of progressive multifocal leukoencephalopathy ..with vedolizumab?  The authors are not certain.  But they state that after reviewing 54,619 patient-years “there have been no cases of PML reported in association with vedolizumab use.”

LCT Buer et al. Inflamm Bowel Dis 2018; 24: 997-1004. This case report of 10 patients describes combination therapy with anti-TNF therapy with vedolizumab. “At the end of follow-up, all patients were in clinical remission, and 8 patients could discontinue anti-TNF treatment.”

OJ Adedokun et al. Gastroenterol 2018; 154: 1660-71. This study examined pharmocokinetics and response of ustekinumab in patients with Crohn’s disease from 701 patients in phase 3 studies..  “Trough concentrations was approximately threefold higher in patients given ustekinumab at 8-week intervals compared with 12-week intervals…Trough concentrations of 0.8 (or even up to 1.4 mcg/mL) or greater were associated with maintenance of clinical remission.”  Also, “concentrations of ustekinumab did not seem to be affected by cotreatment with immunomodulators.”

View from Pine Mountain

Predicting the Need for Gastrojejunostomy Tube Placement Instead of Gastrostomy Tube Placement

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A recent study (ME McSweeney et al. JPGN 2018; 66: 887-92) determined that preoperative characteristics were unable to determine which patients who had gastrostomy tube (GT) placement would ultimately need conversion to gastrojejunostomy (GJ) placement.

This retrospective study matched 79 GJ patients with 79 GT patients.

Key points: 

  • These patients had similar rates of successful preoperative nasogastric feeding trials (GT 84.5% vs GJ 83.1%), and similar rates of abnormal swallow studies (53.8% and 62.2% respectively).
  • In the entire cohort, 11 patients had fundoplication (all GJ patients)
  • GT patients were more likely to have tube permanently removed: 20.5% vs 2.5% for GJ patients. Many (45.6%) of the GJ converted patients went back to GT feeds
  • Overall, from an initial cohort of 902 patients, 8.8% “required conversion” to GJ feeds
  • GJ-converted patients had a trend towards fewer hospitalizations.

While not a result in the study, the issue of GJ compared with fundoplication is briefly discussed.  The authors in their discussion of preoperative workup state that

“the complications of fundoplication are more significant and the risks are higher than GJ placement”

In my view, this is one of the most consequential parts of their discussion.  While the authors have extensive experience, I think the issue regarding GJ tube placement and fundoplication is more murky.  GJ tubes can be difficult to maintain and I have not seen long-term well-controlled studies comparing outcomes between GJ placement and fundoplication.

Other pointers in the discussion:

  • Fundoplication has “minimal impact/no impact” to reduce respiratory-related admissions, mainly because the main mechanism is aspiration rather than reflux
  • For isolated oropharyngeal dysphagia, one could argue that “an enteral tube is not indicated anymore” based on published data

My take: This is an important retrospective study that illustrates how difficult it is to know preoperatively which patients need GJ placement (or fundoplication) compared to GT placement alone.  In our institution, we are reluctant to place GT placement if a patient has not demonstrated tolerance of nasogastric feeds.

Related blog posts:

Amelia Island