Hereditary diffuse gastric cancer: One family's story

Hereditary diffuse gastric cancer (HDGC) is an inherited form of gastric cancer that carries a poor prognosis. Most HDGCs are caused by an autosomal dominant genetic mutation in the CDH1 gene, which carries a 70%-80% lifetime risk of gastric cancer. Given its submucosal origin, endoscopic surveillance is an unreliable means of early detection, and prophylactic gastrectomy is recommended for CDH1 positive individuals older than age 20 years. We describe the case of a male with recurrent gastric cancer who was diagnosed with HDGC secondary to the CDH1 mutation, and we also describe the patient's pedigree and outcomes of recommended genetic testing.

Ileal Pouch Anal Anastomosis for the Management of Ulcerative Colitis Is Associated With Significant Disability

BACKGROUND & AIMS

Disability in patients with medically refractory ulcerative colitis (UC) after total proctocolectomy (TPC) with ileal pouch anal anastomosis (IPAA) is not well understood. The aim of this study was to compare disability in patients with IPAA vs medically managed UC, and identify predictors of disability.

METHODS

This was a multicenter cross-sectional study performed at 5 academic institutions in New York City. Patients with medically or surgically treated UC were recruited. Clinical and socioeconomic data were collected, and the Inflammatory Bowel Disease Disability Index (IBD-DI) was administered to eligible patients. Predictors of moderate-severe disability (IBD-DI ≥35) were assessed in univariable and multivariable models.

RESULTS

A total of 94 patients with IPAA and 128 patients with medically managed UC completed the IBD-DI. Among patients with IPAA and UC, 35 (37.2%) and 30 (23.4%) had moderate-severe disability, respectively. Patients with IPAA had significantly greater IBD-DI scores compared with patients with medically managed UC (29.8 vs 17.9; P < .001). When stratified by disease activity, patients with active IPAA disease had significantly greater median IBD-DI scores compared with patients with active UC (44.2 vs 30.4; P = .01), and patients with inactive IPAA disease had significantly greater median IBD-DI scores compared with patients with inactive UC (23.1 vs 12.5; P < .001). Moderate-severe disability in patients with IPAA was associated with female sex, active disease, and public insurance.

CONCLUSIONS

Patients with IPAA have higher disability scores than patients with UC, even after adjustment for disease activity. Female sex and public insurance are predictive of significant disability in patients with IPAA.

A prospective open-label trial of Remicade in patients with severe exacerbation of Crohn's disease requiring hospitalization: a comparison with outcomes previously observed in patients receiving intravenous hydrocortisone

PURPOSE

To evaluate treatment response to intravenous (IV) infliximab (IFX) as a first-line therapy in patients hospitalized for severe Crohn's disease and compare it with our earlier data using IV hydrocortisone.

METHODS

Seventeen cases received IFX (5 mg/kg) and were matched for the same goal of therapy to those who had received hydrocortisone (300 mg/d). The Crohn's and Colitis Foundation of America-International Organization of Inflammatory Bowel Disease (CCFA-IOIBD) score was obtained for the IFX-treated cases on admission and daily and the Crohn's disease activity index (CDAI) score weekly throughout the hospitalization and compared with those who received hydrocortisone. Discharge was guided by the same criteria in both groups.

RESULTS

For the IFX group, the admission mean CCFA-IOIBD score was 13.5 (+/-4.4). Eight of 17 patients achieved a clinical response with a mean score of 4 (+/-1.5), representing a >or=50% reduction from baseline to discharge. The mean admission score for the hydrocortisone group was 17.75 (+/-7.1) with 13 of 16 achieving a mean score of 4.5 (+/-2.3). The mean discharge score for the 17 IFX patients was 6.9 (+/-3) and for the hydrocortisone group was 5.9 (+/-3.2). Median length of hospitalization for the IFX patients was 4 days (range 1 to 9) and 7.5 (5 to 15) days for the hydrocortisone group (P<0.001).

CONCLUSIONS

IFX therapy was an effective first-line agent in patients with severe Crohn's disease who require hospitalization and therefore a primary treatment option. Most patients receiving IFX can anticipate a briefer hospitalization than with IV hydrocortisone. Failure of an early response can provide an opportunity to consider an alternate form of therapy sooner with IFX than with hydrocortisone.

COVID-19 is not associated with worse long-term inflammatory bowel disease outcomes: a multicenter case-control study

BACKGROUND

Inflammatory bowel disease (IBD) is not associated with worse coronavirus disease 2019 (COVID-19) outcomes. However, data are lacking regarding the long-term impact of severe acute respiratory syndrome coronavirus 2 infection on the disease course of IBD.

OBJECTIVES

We aimed to investigate the effect of COVID-19 on long-term outcomes of IBD.

DESIGN

We performed a multicenter case-control study of patients with IBD and COVID-19 between February 2020 and December 2020.

METHODS

Cases and controls were individuals with IBD with presence or absence, respectively, of COVID-19-related symptoms and confirmatory testing. The primary composite outcome was IBD-related hospitalization or surgery.

RESULTS

We identified 251 cases [ulcerative colitis (n = 111, 45%), Crohn's disease (n = 139, 55%)] and 251 controls, with a median follow-up of 394 days. The primary composite outcome of IBD-related hospitalization or surgery occurred in 29 (12%) cases versus 38 (15%) controls (p = 0.24) and on multivariate Cox regression, COVID-19 was not associated with increased risk of adverse IBD outcomes [adjusted hazard ratio (aHR): 0.84, 95% confidence interval [CI]: 0.44-1.42]. When stratified by infection severity, severe COVID-19 was associated with a numerically increased risk of adverse IBD outcomes (aHR: 2.43, 95% CI: 1.00-5.86), whereas mild-to-moderate COVID-19 was not (aHR: 0.68, 95% CI: 0.38-1.23).

CONCLUSION

In this case-control study, COVID-19 did not have a long-term impact on the disease course of IBD. However, severe COVID-19 was numerically associated with worse IBD outcomes, underscoring the continued importance of risk mitigation and prevention strategies for patients with IBD during the ongoing COVID-19 pandemic.

The impact of corticosteroid use on inpatients with inflammatory bowel disease and positive polymerase chain reaction for Clostridium difficile

BACKGROUND/AIMS

Optimal management of inflammatory bowel disease (IBD) with concomitant Clostridium difficile infection (CDI) is controversial, especially when CDI diagnosis is made by polymerase chain reaction (PCR) testing, which may reflect colonization without infection.

METHODS

We performed a multicenter review of all inpatients with IBD and PCR diagnosed CDI. Outcomes included length of stay, 30- and 90-day readmission, colectomy during admission and within 3 months, intensive care unit (ICU) admission, CDI relapse and death for patients who received corticosteroid (CS) after CDI diagnosis versus those that did not. Propensity-adjusted regression analysis of outcomes based on CS usage was performed.

RESULTS

We identified 177 IBD patients with CDI, 112 ulcerative colitis and 65 Crohn's disease. For IBD overall, CS after CDI diagnosis was associated with prolonged hospitalization (5.5 days: 95% confidence interval [CI], 1.5-9.6 days; P=0.008), higher colectomy rate within 3 months (odds ratio [OR], 5.5; 95% CI, 1.1-28.2; P=0.042) and more frequent ICU admissions (OR, 7.8; 95% CI, 1.5-41.6; P=0.017) versus no CS. CS use post-CDI diagnosis in UC patients was associated with prolonged hospitalization (6.2 days: 95% CI, 0.4- 12.0 days; P=0.036) and more frequent ICU admissions (OR, 7.4; 95% CI, 1.1-48.7; P=0.036).

CONCLUSIONS

CS use among IBD inpatients with CDI diagnosed by PCR is associated with poorer outcomes and would seem to reinforce the importance of C. difficile toxin assay to help distinguish colonization from infection. This adverse effect appears more prominent among those with UC.

Sclerosing Mesenteritis Causing Chylous Ascites and Small Bowel Perforation

BACKGROUND Sclerosing mesenteritis (SM) is a rare idiopathic inflammation and fibrosis of the mesentery. Its etiology and pathogenesis remain unclear. It has been linked to abdominal trauma related to peritoneal dialysis, recent abdominal surgery, idiopathic inflammatory disorder, paraneoplastic syndrome, ischemia/infection, and autoimmunity. Abdominal CT is the most sensitive imaging modality, and diagnosis is usually confirmed by surgical biopsy. Patients most often present with abdominal pain, nausea, vomiting, diarrhea, and weight loss, and less commonly with chylous ascites and small bowel obstruction. Treatment is usually supportive; surgical intervention may be attempted for life-threatening complications such as bowel obstruction or perforation. CASE REPORT This report describes an 80-year-old man with hypertension and end-stage renal disease (ESRD) presenting with increasing abdominal pain and tenderness over the past 5 months. Abdominal enhanced computed tomography (CT) revealed a fat-ring sign and peritoneal calcifications along the serosa surface of small bowel consistent with sclerosing mesenteritis. His hospital course was complicated by increasing ascites requiring multiple ultrasound-guided paracentesis, worsening leukocytosis, and persistent hypotension after dialysis, requiring pressor support. Ascitic fluid analysis was consistent with chylous ascites. The patient subsequently developed small bowel obstruction causing focal perforation, leading to the death of our patient. In this report, we review the clinical presentation, radiographic findings, treatment, and outcome in our patient and review the relevant literature. CONCLUSIONS Diagnosis of sclerosing mesenteritis is challenging due to its nonspecific clinical features. Sclerosing mesenteritis is a debilitating albeit self-limiting disorder that can rarely become fulminant, largely due to its complications.

Racial and ethnic disparities in clinical presentation, management, and outcomes of patients with inflammatory bowel disease: a narrative review

BACKGROUND AND OBJECTIVE

Inflammatory bowel disease (IBD) is a chronic condition that has been increasing in prevalence and incidence worldwide. Although, most cases are described in Caucasian populations, there has been a rise in IBD diagnosis among other populations. In this article, we will discuss the disparities in the presentation, management, medical and surgical outcomes of IBD patients among different racial and ethnic groups.

METHODS

A literature search was conducted in PubMed, Medline, and Google Scholar. The search strategy included targeted keywords to identify specific studies that provided the current literature on disparities in IBD presentation and management. Articles for presentation were selected by the authors, in accordance with a narrative review format, favoring population-based studies, systematic reviews and meta-analysis over single or multicenter reports.

KEY CONTENT AND FINDINGS

Epidemiological data has shown that there is an increasing incidence in IBD diagnosis among Black, Asian, and Hispanic populations over the past decade. Differences in genetic predispositions have been observed, however it is difficult to ascertain if the minor differences in presentation and medical/surgical management reported are due to innate differences or due to confounding factors such as access to health care.

CONCLUSIONS

Differences in genetic predisposition, and clinical presentation have been observed to exist among IBD non-Caucasian populations. There were also differences observed in both surgical and medical management, but it is difficult to ascertain if these were innate differences or due to societal factors.

An elderly patient's complete response to steroid therapy for collagenous gastritis

An 85-year-old woman presented with 9.1 kg (20 lb) weight loss over 5 months and an acute onset crampy abdominal pain. Examination revealed a diffusely tender abdomen, with gastric wall thickening noted on CT scan. Upper endoscopy showed diffuse severe erythema and friability. Histologic examination with hematoxylin and eosin staining revealed collagenous gastritis characterized by active chronic inflammation with sub-epithelial collagen deposition and erosion. The patient was started on steroid therapy with rapid clinical improvement and tapered off over 2.5 months. At 6 months, the patient reported an improved appetite with resolution of her abdominal pain. Repeat endoscopy revealed a grossly normal stomach and normal mucosal biopsies. She remains without complaints 1 year later. Collagenous gastritis, rare in the elderly, is a histologic diagnosis characterized by the deposition of a sub-epithelial collagen band thicker than 10 µm with an inflammatory infiltrate. In all ages the mucosa typically appears nodular and erythematous, caused by an uneven inflammation in the surrounding depressed mucosa with atrophic changes. Specific therapy has not been well-established, and the prognosis and potential for endoscopic or histological resolution remains unclear. While anecdotal, the success of steroids may offer a reasonable starting point for treatment of similar cases.

Infliximab as Rescue Therapy for Hospitalized Patients With Crohn's Disease Failing Intravenous Corticosteroids

BACKGROUND

Infliximab (IFX) has been shown to be effective rescue therapy for hospitalized ulcerative colitis patients failing intravenous (IV) corticosteroids (CS). There is little evidence, however, describing its use in similar hospitalized Crohn's Disease (CD) patients.

STUDY QUESTION

To determine if IFX is an effective rescue therapy for IV CS resistant CD patients.

STUDY DESIGN

A retrospective study of inpatients with CD who received IFX as rescue therapy at 2 tertiary care hospitals from January 1, 2006, to December 31, 2016. Records were reviewed for demographics, disease activity, preadmission and inpatient treatment, surgical rates, and 30- and 90-day readmission rates. Measures and Outcomes: Efficacy of IFX as rescue therapy was defined by discharge without surgery and readmission rates. Only patients failing IV CS before IFX were included in the final analysis.

RESULTS

Forty patients received IFX, of which 17 had failed IV CS. Four patients were receiving outpatient IFX therapy, but still received IV CS during hospitalization before IFX. The mean duration of IV CS therapy before IFX was 6.9 days. Of the 15 patients (88%) who responded to rescue IFX, the median hospital stay following IFX was 3 days (range 3-18 days). Readmission rates were 29% and 47% at 30 and 90 days respectively, without further surgeries noted.

CONCLUSIONS

In our series of hospitalized CD patients failing IV CS, those treated with IFX had low rates of urgent surgery and a generally rapid response to treatment, supporting IFX as an effective rescue therapy. By only including those with prior failure of IV CS, we have likely excluded patients for whom IFX was given in the hospital for reasons other than severe disease. Our results suggest that individuals with severe acute CD flare can be treated with early introduction of IFX, avoiding prolonged CS use, and hospitalization.

Letter: fighting the battle but losing the war-inflammatory bowel disease and venous thromboembolism

LINKED CONTENT

This article is linked to Faye et al papers. To view these articles, visit https://doi.org/10.1111/apt.17162 and https://doi.org/10.1111/apt.17227

Declining use of combination infliximab and immunomodulator for inflammatory bowel disease in the community setting

AIM

To describe trends of combination therapy (CT) of infliximab (IFX) and immunomodulator (IMM) for inflammatory bowel disease (IBD) in the community setting.

METHODS

A retrospective study was conducted of all IBD patients referred for IFX infusion to our community infusion center between 04/01/01 and 12/31/14. CT was defined as use of IFX with either azathioprine, 6-mercaptopurine, or methotrexate. We analyzed trends of CT usage overall, for Crohn's disease (CD) and ulcerative colitis (UC), and for the subgroups of induction patients. We also analyzed the trends of CT use in these groups over the study period, and compared the rates of CT use prior to and after publication of the landmark SONIC trial.

RESULTS

Of 258 IBD patients identified during the 12 year study period, 60 (23.3%) received CT, including 35 of 133 (26.3%) induction patients. Based on the Cochran-Armitage trend test, we observed decreasing CT use for IBD patients overall (P < 0.0001) and IBD induction patients, (P = 0.0024). Of 154 CD patients, 37 (24.68%) had CT, including 20 of 77 (26%) induction patients. The Cochran Armitage test showed a trend towards decreasing CT use for CD overall (P < 0.0001) and CD induction, (P = 0.0024). Overall, 43.8% of CD patients received CT pre-SONIC vs 7.4% post-SONIC (P < 0.0001). For CD induction, 40.0% received CT pre-SONIC vs 10.8% post-SONIC (P = 0.0035). Among the 93 patients with UC, 19 (20.4%) received CT. Of 50 induction patients, 14 (28.0%) received CT. The trend test of the 49 patients with a known year of induction again failed to demonstrate any significant trends in the use of CT (P = 0.6).

CONCLUSION

We observed a trend away from CT use in IBD. A disconnect appears to exist between expert opinion and evidence favoring CT with IFX and IMM, and evolving community practice.

Corticosteroid and Biologic Use Not Associated With Adverse Outcomes for Inflammatory Bowel Disease Patients Hospitalized With COVID-19

BACKGROUND

To date, studies investigating the inflammatory bowel disease (IBD) patient experience with coronavirus disease 2019 (COVID-19) have consistently reported that the observed rate of COVID-19 within this population is similar to the general population. Limited research has suggested that corticosteroid use in the IBD population may be associated with worse COVID-19 outcomes, but it is still yet to be determined if specific IBD-related clinical factors are associated with worse outcomes. Our goal was to describe clinical COVID-19 outcomes for IBD patients and to identify the clinical factors that may be associated with worse outcomes.

METHODS

In this retrospective study, we utilized the inpatient database within the largest hospital network in the New York City Metropolitan area to identify all IBD patients with confirmed COVID-19.

RESULTS

Of 83 IBD/COVID-19 patients presenting to a hospital network emergency room, 56 were hospitalized. Overall, 19.6% of hospitalized IBD patients died, compared with 22.2% of all hospital system COVID-19 patients during the time period. There was no association between pre-admission corticosteroid use or biologic treatment with a severe course of COVID-19.

CONCLUSIONS

In contrast to some prior reports, we did not observe an association of pre-admission corticosteroid use and adverse outcomes. While the mortality rate was high for IBD/COVID-19 patients, it was not greater than that for hospitalized COVID-19 patients generally. Though our results are encouraging, we continue to support the recommendations of the leading gastrointestinal and IBD societies to regard our patients as "at risk", and to observe caution in their care.

Correction: Vedolizumab for Ulcerative Colitis: Treatment Outcomes from the VICTORY Consortium

This Article was originally published under Nature Research's License to Publish, but has now been made available under a CC BY-NC-ND license. The PDF and HTML versions of the Article have been modified accordingly.

Back to the drawing board: Overview of the next generation of combination therapy for inflammatory bowel disease

Inflammatory bowel disease (IBD) is entering a potentially new era of combined therapeutics. Triantafillidis et al provide an insightful review of the current state of combination therapy, with a focus on the use of a combined biologic and immunomodulator, as well as emerging data on the future potential of dual-biologic therapy (DBT). While current evidence for DBT is limited, encouraging safety profiles and ongoing trials suggest a brighter future for this approach. The importance of controlled trials should be stressed in establishing new treatment paradigms. Ongoing prospective randomized trials of DBT and perhaps future combinations of biologics and small molecule therapies will hopefully guide the next generation of IBD care.

Emerging role of small ribonucleic acids in gastrointestinal tumors

Small regulatory ribonucleic acids (RNAs) are recently recognized as being connected with a growing list of common diseases such as: cancer, heart disease, diabetes and inflammation and to date more than 5,000 publications are recorded on PubMed alone. Specific pathways generate each class of RNAs and their activities converge in the process of silence interference. In gastrointestinal malignancies microRNAs are deregulated, sometimes found in higher or lower levels depending on the type of malignancy and stage of the disease, functioning either as tumor suppressors or as oncogenes they interact forming regulatory loops with known transcription factors and signaling pathways. MiRNAs extracted from archived tissue biopsies can be used effectively as diagnostic, prognostic tools and molecular markers because they are stable over time and resistant to RNAse degradation. The distinct physiology of small RNAs may translate in more targeted cancer therapies in the near future.

Pharmacologic Anticoagulation Is Associated With a Lower Risk of Recurrent Venous Thromboembolic Events During Janus Kinase Inhibitor Use for Patients With a Prior Thrombosis

BACKGROUND

Janus kinase (JAK) inhibitors tofacitinib and upadacitinib are effective therapies for inflammatory bowel disease and rheumatologic disorders but currently possess a warning for increased venous thromboembolism (VTE) risk. Some patients with a history of VTE may benefit from a JAK inhibitor, but the risk of recurrent VTE with JAK inhibitor use is unclear. Our goal was to observe rates of new VTE events after starting JAK inhibitor therapy in patients with a prior VTE, and observe whether concurrent anticoagulation (AC) reduces this risk.

METHODS

We conducted a review of adults prescribed tofacitinib or upadacitinib between January 1, 2000, and June 30, 2023, with a prior history of VTE. Patient charts were reviewed for demographic data, disease type, and VTE date(s), and to verify duration of JAK inhibitor use along with any concurrent AC. VTEs following JAK inhibitor initiation were identified by International Classification of Diseases-Tenth Revision code and verified by physician documentation and imaging.

RESULTS

We identified 79 patients with a documented VTE history before initiating JAK inhibitors, 47 of whom began a JAK inhibitor with concurrent AC. Of these, 15 patients discontinued AC while receiving JAK inhibitors. In total, 5 new VTE events were observed during 55.42 patient-years of JAK inhibitor treatment without concurrent AC (9.0 events per 100 patient-years), while no new VTE events occurred during 65.2 patient-years of JAK inhibitor treatment with concurrent AC, demonstrating a lower risk of recurrent VTE (P = .020).

CONCLUSIONS

These results suggest that for patients with a prior VTE history there is a high risk for recurrent VTE while receiving JAK inhibitors. Concurrent use of AC with JAK inhibitors appears to be protective against recurrent VTEs in this population.

Reactive Immunomodulator Addition to Infliximab Monotherapy Restores Clinical Response in Inflammatory Bowel Disease: A Meta-Analysis

BACKGROUND AND AIMS

Patients with inflammatory bowel disease (IBD) receiving infliximab (IFX) commonly experience immunogenic loss of response (LOR) by formation of anti-drug antibodies (ADAs). An immunomodulator (IMM) used in combination with initial IFX induction is known to reduce ADA development and improve clinical outcomes. We aimed to assess the impact of reactively adding an IMM to patients on IFX monotherapy.

METHODS

We conducted a retrospective cohort study and systematic review with meta-analysis of patients with IBD demonstrating immunologic LOR, with or without clinical LOR, that had an IMM (azathioprine, 6-mercaptopurine, or methotrexate) reactively added (reactive combination therapy; rCT) to combat elevated ADAs and raise IFX level. Data were extracted for pooled effect size estimation using random-effects models, and ADA and IFX trough levels were compared pre- and post-IMM initiation.

RESULTS

We identified 6 patients who received rCT due to rising ADA titers and low IFX levels. Median ADA titer decreased from 506 ng/mL (interquartile range (IQR) [416-750]) to 76.5 ng/mL (IQR [25.8-232]), an 85% decrease (p = 0.031). Median IFX trough increased from 0.4 µg/mL (IQR [0.4-0.48]) to 8.25 µg/mL (IQR [3.7-9.6]), a 20.6-fold increase (p = 0.038). Meta-analysis pooled effect size of 7 studies with 89 patients showed an 87% ADA titer reduction [95% confidence interval (CI) = 72-94%], 6.7-fold increased IFX trough (95% CI = 2.4-18.7), and 76% clinical remission rescue rate (95% CI = 59-93%).

CONCLUSIONS

These results suggest rCT is a valid rescue strategy in patients with immunogenic LOR to IFX to reduce ADA titers, restore therapeutic IFX levels, and recapture clinical remission of IBD.