Crohn’s Disease Anastomotic Ulcerations

Posted on by

A recent retrospective study (RP Hirten et al. Inflamm Bowel Dis 2020; 26: 1050-1058. Anastomotic Ulcers After Ileocolic Resection for Crohn’s Disease Are Common and Predict Recurrence) showed that anastomotic ulcers occur in over half of Crohn’s disease patients after ileocolic resection and are associated with Crohn’s disease recurrence and are persistent.

Key findings:

  • Anastomotic ulcers were present in 95 (52.2%) subjects. No factors were associated with anastomotic ulcer development.
  • Anastomotic ulcers were associated with disease recurrence (adjusted hazard ratio [aHR] 3.64)

The associated editorial by Philllip Fleshner (pg 1059) identifies are a number of methodologic flaws, noting that less than 20% of all ileocolonic resections were included and marked variability in postoperative assessment (from 29 days to 2897 days).

My take: (borrowed from the editorial) the “findings should convince us that anastomotic ulcers do not represent ischemic changes but are rather a reflection of disease progression.”  Prospective studies with standardized surveillance would be helpful.

 

What GI Doctors Should Know About Anti-Reflux Surgery

Posted on by

This is a useful review -with helpful diagrams: Full text Ten Things Every Gastroenterologist Should Know About Antireflux Surgery (S Park et al. Clin Gastroenterol Hepatol 2020; 18: 1923-1929)

A couple excerpts:

Selecting Patients for Surgery: Current guidelines fall short in determining appropriate patients who would benefit most from surgery. For instance, the recommendation that a desire to discontinue PPI therapy is a suitable indication for antireflux surgery fails to recognize that 62% of patients end up back on PPIs within 9 years. Furthermore, indicating that those patients who failed medical management would benefit from surgery neglects the fact that the patients who respond best to antireflux surgery are those who have responded well to PPI therapy in the first place

Complications: Late postoperative complaints are more common and often are referred back to the referring gastroenterologist for diagnosis and management. These include late-onset dysphagia (3%–24%), recurrent heartburn (up to 62%), gas-bloat syndrome (up to 85%), and diarrhea (18%–33%).  Anatomic failure of the fundoplication (Figure Below) can present a unique challenge to the clinician because the symptoms and patient presentation (postoperative dysphagia, regurgitation, and heartburn) can be clinically indistinct from the issues seen commonly after this surgery even in the best of circumstances.  Therefore, the gastroenterologist should assess symptoms carefully in a stepwise approach with upper endoscopy, barium swallow, esophageal manometry, and/or ambulatory pH monitoring when appropriate and plan any interventions based on objective findings from focused testing.

Other points:
  • Antireflux Surgery Has No Significant Impact on the Progression of Barrett’s Esophagus to Esophageal Adenocarcinoma: Endoscopic Ablation of Dysplastic Barrett’s Esophagus Still Is Recommended
  • Medical Therapy Is More Cost Effective Than Surgical Treatment if the Cost of the Drug Is Low
  • Several New, Less-Invasive Surgical and Endoscopic Antireflux Procedures Are Now Food and Drug Administration Approved, Available, and Appear Promising

Related blog posts:

Flu Vaccine in Pregnant Women Did NOT Increase Risk of Autism

Posted on by

JV Ludvigsson et al. Annals of Internal Medicine 2020; https://doi.org/10.7326/M20-0167. Full Text: Maternal Influenza A(H1N1) Immunization During Pregnancy and Risk for Autism Spectrum Disorder in Offspring

  • In total, 39 726 infants were prenatally exposed to H1N1 vaccine (13 845 during the first trimester) and 29 293 infants were unexposed.
  • Mean follow-up was 6.7 years .
  • 394 (1.0%) vaccine-exposed and 330 (1.1%) unexposed children had a diagnosis of ASD.

My take (borrowed from authors): This large cohort study found no association between maternal H1N1 vaccination during pregnancy and risk for ASD in the offspring.

Nonceliac Gluten and Wheat Sensitivity: Review

Posted on by

A Khan et al. Clin Gastroenterol Hepatol 2020; 18: 1913-1922. Nonceliac Gluten and Wheat Sensitivity

This useful review notes that ” there is a great deal of skepticism within the scientific community questioning the existence of NCGS as a distinct clinical disorder.”

Key points:

  • The pathogenesis of NCGS is unclear and there is no known biomarker or diagnostic histologic lesion for this condition.
  • In these suspected patients, it is important to first exclude celiac disease and wheat allergy (especially if a rash with eating). If celiac disease is identified, this allows for appropriate longitudinal followup, strict dietary instructions, and potential screening of at-risk family members.
  • Recent studies have shown that GI symptoms in those labelled with NCGS are frequently due to dietary FODMAPs.
  • In a large meta-analysis study with 1312 adults, only 16% of participants experience gluten-specific symptoms using a double-blind placebo-controlled rechallenge.  In addition, 40% of participants experienced a nocebo response (ie. a greater negative effect than usual due to negative expectation from a dietary treatment)
  • In clinical practice, a single blind placebo-controlled rechallenge trial has been recommended for diagnosis

My take: GFD is often unnecessary and ineffective, even in those who have previously identified gluten as a potential food trigger.  Fructans are more likely to induce gastrointestinal symptoms.

Related blog posts:

Misty morning -Chattahoochee River, Island Ford

Put Your Own Oxygen Mask On First

Posted on by

D Atkins. Annals of Internal Medicine 2020; https://doi.org/10.7326/M20-6349. Put Your Own Oxygen Mask On First

Important commentary -here’s an excerpt:

My hope that his colleagues would honor his memory by spending time taking care of themselves. “Selflessness has its price. Skip was so ready to give someone the shirt off his back that he may not have realized when he was also cold. I hope each of you—especially those of you who are doctors and nurses and caregivers—will take time to be selfish when you need to be. Make a lunch date with your Skip to complain about your problems. Put your own oxygen mask on first.”

Alterations in Microbes and Impaired Psychological Function in Patients with Inflammatory Bowel Disease

Posted on by

Briefly noted: F Humbel et al. Clin Gastroenterol Hepatol 2020; 18: 2019-2029. Association of Alterations in Intestinal Microbiota With Impaired Psychological Function in Patients With Inflammatory Bowel Diseases in Remission

In a prospective study with 171 adults with IBD in remission, the authors combined

  1. measures of psychological comorbidities and quality of life (QoL)
  2. microbial analysis with 16S rRNA high-throughput sequencing

Key findings:

  • Microbiomes of patients with higher perceived stress had significantly lower alpha diversity
  • Anxiety and depressive symptoms were significantly associated with beta diversity

My take: This study adds another dimension to the idea of bidirectionality between psychological well-being and course of inflammatory bowel disease.  The microbiome may directly influence both psychological well-being and IBD activity.

Related blog posts:

“Positioning Biologic Therapies in the Management of Pediatric Inflammatory Bowel Disease” & 14% of U.S. Infected with COVID-19

Posted on by

J Breton et al. Gastroenterology & Hepatology 2020; 16: 400-14. Full text: Positioning Biologic Therapies in the Management of Pediatric Inflammatory Bowel Disease

This is a terrific summary of biologic therapies for pediatric inflammatory bowel disease. Compared to adults, the pediatric data is much more limited.  This may affect recommendations.  For example, recent AGA guidelines for moderate to severe ulcerative colitis in adults suggests that either ustekinumab or tofacitinib is generally preferable as a 2nd line agent rather than vedolizumab in patients with primary infliximab failure (Blog post: AGA Guidelines: Moderate to Severe Ulcerative Colitis).  In the chart below, vedolizumab is recognized as a preferred 2nd line agent.

In the section on vedolizumab:

The favorable risk-benefit profile makes vedolizumab an ideal therapeutic choice for pediatric IBD. However, an important limitation is its delayed onset of action, for which corticosteroid use as bridge therapy is often necessary in this population that is already at increased risk of growth failure and bone loss. Recently, Hamel and colleagues published their small, single-center experience of using concomitant tacrolimus between anti-TNFα withdrawal to vedolizumab maintenance as a corticosteroid-sparing bridge therapy in moderate to severe IBD (Ref: Hamel B, Wu M, Hamel EO, Bass DM, Park KT. Outcome of tacrolimus and vedolizumab after corticosteroid and anti-TNF failure in paediatric severe colitis. BMJ Open Gastroenterol. 2018;5(1):e000195).

This article addresses therapeutic drug monitoring:

TDM is a key component of managing IBD patients on anti-TNFα therapy. While  reactive TDM of antiTNFα agents has been adopted by societal guidelines, there is an increasing body of literature to support the benefit of proactive TDM, particularly in pediatric populations

Conclusions from authors: Anti-TNFα agents have revolutionized the management of IBD, positively modifying the natural disease history in children. Importantly, inception cohort studies of pediatric CD and UC (RISK and PROTECT, respectively) have highlighted the variable course of disease and necessity of adopting an individualized approach with early use of biologic therapy in patients at risk of severe disease progression. 

Biologics Used in Pediatric Inflammatory Bowel Disease

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  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

Hemospray Efficacy and Rebleeding

Posted on by

A Ofusu et al. J Clin Gastroenterol 2020. doi:10.1097/MCG.0000000000001379. The Efficacy and Safety of Hemospray for the Management of Gastrointestinal Bleeding

This systematic review and meta-analysis included 19 studies and 814 patients.

  • 212 patients were treated with Hemospray as monotherapy
  • 602 patients were treated with Hemospray with conventional hemostatic techniques.

Key findings:

  • Overall pooled clinical success after the application of Hemospray was 92%
  • Overall pooled early rebleeding rates (<7 days) after application of Hemospray was 20%
  • Overall pooled delayed rebleeding rates after the application of Hemospray was 23% (<30 days)
  • There was no statistical difference in clinical success (RR, 1.02; 95% CI, 0.96-1.08; P=0.34) and early rebleeding (RR, 0.89; 95% CI, 0.75-1.07; P=0.214) in studies that compared the use of Hemospray as monotherapy versus combination therapy with conventional therapy.

Related study: D Chahal et al. Dig Liver Dis 2020. DOI: https://doi.org/10.1016/j.dld.2020.01.009 Full text: High rate of re-bleeding after application of Hemospray for upper and lower gastrointestinal bleeds Findings (n=86): Immediate hemostasis rate was 88.4%, but there was a high rate of re-bleeding (33.7%). Most re-bleeds occurred within 7 days (86.2%)

My take: Hemospray is effective in achieving immediate hemostasis but there are high rates of rebleeding. It may be eliminated by GI tract in as few as 24 hours after use.  Thus, for lesions at high risk for bleeding, hemospray is likely more of a last resort endoscopic option.

Related blog posts:

Nutrition4Kids and Nutrition4IBD

Posted on by

My colleague and partner, Stan Cohen, along with his outstanding advisory board, have put together two terrific (free) resources for both children and adults:

Both are up-to-date, user-friendly, authoritative and attractive websites that feature advice families can trust to help them understand their disease and options to live as full a life as possible. Between the two, there are:

  • Over 700 articles
    • Nutrition4Kids Categories: Eating at different ages, Healthy lifestyle, Nutrients, Diseases and disorders and Patient experience
    • Nutrition4IBD Categories: Understanding IBD, Treatment Options, Nutrition for IBD and Patient options.
  • Over 60 videos including 35 on food allergies (including FPIES and eosinophilic disorders) and 14 on tube-feedings, including one about a lacrosse player that is quite inspirational.
  • Amazing tools:
    • A food log and a symptom diary that patients can download to record how they are doing
    • a BMI calculator
    • a table of milk alternatives (created by our nutritionist Bailey Koch)
    • a tool which provides over 150,000 food labels for restaurant and packaged foods.
    • a cool tool where a patient can indicate their age, gender, whether they’re breastfeeding or pregnant (even which trimester they’re in), and it will tell what’s in over 200,000 foods and what nutrients and calories they need.
  • Healthy recipes with their nutrient values per serving.
  • This website relies on a group of 42 contributors including many from our group, psychologists, speech-language pathologists, nurses, dietitians, and families.
  • Other practices can link to our site, so they can share our medically-curated and accurate content and tools with their patient-families.

Eosinophilic Esophagitis -FAQs

Posted on by

A recent FAQ on Eosinophilic Esophagitis By Ronak Patel, MD  Ikuo Hirano, MD, AGAF: Full Text -GIHepNews (August 2020) Eosinophilic esophagitis: Frequently asked questions (and answers) for the early-career gastroenterologist

One aspect about this review that I liked was the dietary step-up –step-down therapy figure:

Reference: J Molina-Infante et al. J Allergy and Clincal Immunology. DOI:https://doi.org/10.1016/j.jaci.2017.08.038 Step-up empiric elimination diet for pediatric and adult eosinophilic esophagitis: The 2-4-6 study Results:  A TFGED (2-food) achieved EoE remission in 56 (43%) patients, with no differences between ages. Food triggers in TFGED responders were milk (52%), gluten-containing grains (16%), and both (28%). EoE induced only by milk was present in 18% and 33% of adults and children, respectively. Remission rates with FFGEDs (4-food) and SFGEDs (6-food) were 60% and 79%, with increasing food triggers, especially after an SFGED. Overall, 55 (91.6%) of 60 of the TFGED/FFGED responders had 1 or 2 food triggers. Compared with the initial SFGED, a step-up strategy reduced endoscopic procedures and diagnostic process time by 20%.

Related blog posts: