Prevalence and risk factors for colonic perforation during colonoscopy in hospitalized inflammatory bowel disease patients

C-reactive protein-to-albumin ratio and neutrophil-to-albumin ratio for predicting response and prognosis to infliximab in ulcerative colitis

The C-reactive protein-to-albumin ratio (CAR) and neutrophil-to-albumin ratio (NAR) serve as established markers for inflammatory diseases. However, limited studies have investigated their potential in predicting response and prognosis following infliximab (IFX) treatment. The objective of this paper was to evaluate feasibility of CAR and NAR as biomarkers to assess response to IFX induction therapy. Additionally, we attempted to determine the capacity to predict clinical remission in ulcerative colitis (UC) after 54 weeks of IFX treatment. We enrolled a total of 157 UC patients diagnosed via endoscopic mucosal biopsy at our hospital between October 2018 and June 2023. Additionally, 199 patients presenting with gastrointestinal symptoms, who underwent physical examinations, constituted the control group. Comprehensive clinical data, laboratory indicators, and endoscopic findings were systematically collected. CAR and NAR values were computed before treatment, post-induction, and subsequently at 8-week intervals. Comparisons between two groups were analyzed using the Wilcoxon rank-sum test or the independent samples t-test, and comparisons between multiple groups were analyzed using the one-way ANOVA (analysis of variance) or the Kruskal-Wallis rank sum test. We found CAR and NAR emerged as sensitive biomarkers for assessing disease activity. Notably, our findings indicated their dual predictive capability: foreseeing response post-IFX induction therapy and prognosticating the likelihood of UC patients achieving clinical remission following 54 weeks on IFX therapy.

MR Enterography in Ulcerative Colitis: Beyond Endoscopy

Ulcerative colitis (UC) is a chronic idiopathic inflammatory bowel disease (IBD) that progressively affects mucosa and submuccosa of the colon and rectum in a continual pattern. In comparison, Crohn disease (CD), the other type of IBD, is a chronic transmural inflammatory disorder that can involve any part of the gastrointestinal tract. MR enterography (MRE) has emerged as an important imaging modality for the diagnosis and detection of disease activity and complications in CD, with comparable results to those of endoscopy. But MRE has been underused for assessment of UC in recent years, and clinicians heavily rely on endoscopic findings for management of UC. Despite UC being considered an endoscopically assessable disease, MRE can provide useful information beyond that obtained with endoscopy about mural or extramural abnormalities, inaccessible parts of the colonic lumen, associated extraintestinal diseases, and superimposed pathologic conditions. Moreover, endoscopy might be contraindicated in some clinical settings due to the risk of colonic perforation. In addition to depicting the features of UC activity in different phases, MRE demonstrates findings of disease chronicity that cannot be achieved with endoscopy, particularly in a patient with colitis of unknown cause. The valuable diagnostic role of MRE to exclude undiagnosed CD in patients with UC who have refractory disease or those with postproctocolectomy complications is also emphasized. Radiologists can play a crucial role in the management of UC with MRE by addressing what is beyond endoscopy. ©RSNA, 2023 Test Your Knowledge questions are available in the supplemental material.

Inflammatory Bowel Disease Is not Linked to a Higher Rate of Adverse Events in Colonoscopy-a Nationwide Population-based Study in Sweden

BACKGROUND AND AIMS

Inflammatory bowel disease may cause long-standing inflammation and fibrosis and may increase the risk of adverse events in colonoscopy. We evaluated whether inflammatory bowel disease and other potential risk factors are associated with bleeding or perforation in a nationwide, population-based, Swedish study.

METHODS

Data from 969 532 colonoscopies, including 164 012 [17%] on inflammatory bowel disease patients, between 2003 and 2019, were retrieved from the National Patient Registers. ICD-10 codes for bleeding [T810] and perforation [T812] within 30 days of the colonoscopy were recorded. Multivariable logistic regression was used to test if inflammatory bowel disease status, inpatient setting, time period, general anaesthesia, age, sex, endoscopic procedures, and antithrombotic treatment were associated with higher odds for bleeding and perforation.

RESULTS

Bleeding and perforation were reported in 0.19% and 0.11% of all colonoscopies, respectively. Bleeding [odds ratio 0.66, p <0.001] and perforation [odds ratio 0.79, p <0.033] were less likely in colonoscopies in individuals with inflammatory bowel disease status. Bleeding and perforation were more common in inpatient than in outpatient inflammatory bowel disease colonoscopies. The odds for bleeding but not perforation increased between 2003 to 2019. General anaesthesia was associated with double the odds for perforation.

CONCLUSIONS

Individuals with inflammatory bowel disease did not have more adverse events compared with individuals without inflammatory bowel disease status. However, the inpatient setting was associated with more adverse events, particularly in inflammatory bowel disease status. General anaesthesia was associated with a greater risk of perforation.

Early Intestinal Ultrasound Predicts Clinical and Endoscopic Treatment Response and Demonstrates Drug-Specific Kinetics in Moderate-to-Severe Ulcerative Colitis

BACKGROUND

Intestinal ultrasound (IUS) is an emerging modality in monitoring disease activity in ulcerative colitis (UC). Here, we aimed to identify early IUS predictors of treatment response as evaluated by endoscopy and assessed the kinetics of IUS changes.

METHODS

This prospective, longitudinal study included UC patients with endoscopic disease activity (endoscopic Mayo score [EMS] ≥2) starting anti-inflammatory treatment. Clinical scores, biochemical parameters and IUS were assessed at baseline (W0), at week 2 (W2), at W6(W6), and at the time of second endoscopy (W8-W26). Per colonic segment, endoscopic remission (EMS = 0), improvement (EMS ≤1), response (decrease in EMS ≥1), and clinical remission (Lichtiger score ≤3) were assessed and correlated with common IUS parameters. Additionally, drug-specific responsiveness of bowel wall thickness (BWT) was assessed.

RESULTS

A total of 51 patients were included and followed, and 33 patients underwent second endoscopy. BWT was lower from W6 onward for patients reaching endoscopic improvement (3.0 ± 1.2 mm vs 4.1 ± 1.3 mm; P = .026), remission (2.5 ± 1.2 mm vs 4.1 ± 1.1 mm; P = .002), and clinical remission (3.01 ± 1.34 mm vs 3.85 ± 1.20 mm; P = .035). Decrease in BWT was more pronounced in endoscopic responders (-40 ± 25% vs -4 ± 28%; P = .001) at W8 to W26. At W6, BWT ≤3.0 mm (odds ratio [OR], 25.13; 95% confidence interval, 2.01-3.14; P = .012) and color Doppler signal (OR, 0.35; 95% confidence interval, 0.14-0.88; P = .026) predicted endoscopic remission and improvement, respectively. Submucosal layer thickness at W6 predicted endoscopic remission (OR, 0.09; P = .018) and improvement (OR, 0.14; P = .02). Furthermore, BWT decreased significantly at W2 for infliximab and tofacitinib and at W6 for vedolizumab.

CONCLUSIONS

BWT and color Doppler signal predicted endoscopic targets already after 6 weeks of treatment and response was drug specific. IUS allows close monitoring of treatment in UC and is a surrogate marker of endoscopy.

Evaluation of intestinal ultrasound for disease activity assessment in patients with inflammatory bowel disease: A cross-sectional study at a tertiary centre in Malaysia

Background

The use of intestinal ultrasound (IUS) in the management of inflammatory bowel disease (IBD) is emerging. We aim to determine the performance of IUS in the assessment of disease activity in IBD.

Methods

This is a prospective cross-sectional study of IUS performed on IBD patients in a tertiary centre. IUS parameters including intestinal wall thickness, loss of wall stratification, mesenteric fibrofatty proliferation, and increased vascularity were compared with endoscopic and clinical activity indices.

Results

Among the 51 patients, 58.8% were male, with a mean age of 41 years. Fifty-seven percent had underlying ulcerative colitis with mean disease duration of 8.4 years. Against ileocolonoscopy, IUS had a sensitivity of 67% (95% confidence interval (CI): 41-86) for detecting endoscopically active disease. It had high specificity of 97% (95% CI: 82-99) with positive and negative predictive values of 92% and 84%, respectively. Against clinical activity index, IUS had a sensitivity of 70% (95% CI: 35-92) and specificity of 85% (95% CI: 70-94) for detecting moderate to severe disease. Among individual IUS parameters, presence of bowel wall thickening (>3 mm) had the highest sensitivity (72%) for detecting endoscopically active disease. For per-bowel segment analysis, IUS (bowel wall thickening) was able to achieve 100% sensitivity and 95% specificity when examining the transverse colon.

Conclusions

IUS has moderate sensitivity with excellent specificity in detecting active disease in IBD. IUS is most sensitive in detecting a disease at transverse colon. IUS can be employed as an adjunct in the assessment of IBD.

Differentiation of Active Ulcerative Colitis vs Noninflammatory Bowel Disease Proctitis by Transperineal Superb Microvascular Imaging

BACKGROUND

Transabdominal ultrasonography and transperineal ultrasonography (TPUS) appear correspond to colonoscopy (CS) for evaluating ulcerative colitis (UC) activity, but their utility in UC diagnosis remains unclear. This research compared the accuracy of TPUS and CS for assessing rectal activity and differentiating noninflammatory bowel disease proctitis from UC in pediatric cases.

METHODS

The study is a blinded, prospective, and controlled trial. Prospectively, values of fecal calprotectin (FCP) and findings of the TPUS and CS were compared between child cases of UC and non-IBD proctitis. Findings of rectal wall thickening (RWT), rectal wall flow (RWF) on power Doppler, and microvascular signal at wall circumference (MSWC) on monochrome superb microvascular imaging assessed using TPUS were compared with the CS.

RESULTS

Thirty patients with Mayo endoscopic subscore (MES) 0 to 1 UC, 57 with MES 2 to 3 UC, and 44 with proctitis were registered. Fecal calprotectin, RWF, and MSWC indicated significant differences among the groups (P < .05). Rectal wall thickening showed no significant difference between MES 0-1 and proctitis (P = .76). Rectal wall thickening and MSWC were independent predictors of endoscopic activity of UC, resulting in a sensitivity and specificity of 100% for RWT ≥4.5 mm and positive MSWC. Fecal calprotectin and RWF were independent predictors for differentiating MES 0 to 1 and proctitis, and FCP and RWT were independent predictors for differentiating MES 2 to 3 and proctitis. Sensitivity and specificity were 77.2% and 80.9%, respectively, for FCP >242.5 μg/g and RWF negative; and they were both 100% for RWT >4.1 mm and MSWC positive.

CONCLUSIONS

Transperineal ultrasonography with mSMI may enable the evaluation of rectal activity and differentiation of UC from non-IBD proctitis with accuracy comparable to endoscopy.

Carbon dioxide insufflation reduces the relapse of ulcerative colitis after colonoscopy: A randomized controlled trial

BACKGROUND AND AIM

Colonoscopy is necessary for diagnosing and surveilling patients with ulcerative colitis, though it may cause disease flares. Colonoscopy with carbon dioxide (CO2) insufflation decreases abdominal discomfort; however, its effect on exacerbation incidence in ulcerative colitis remains unclear. Therefore, this study aimed to evaluate the colonoscopy effects using CO2 insufflation in patients with ulcerative colitis.

METHODS

Overall, 96 remissive patients with ulcerative colitis (partial Mayo score ≤ 2) who underwent total colonoscopy between March 2015 and December 2019 at Osaka University Hospital were enrolled and blindly randomized to the CO2 (n = 45) and air (n = 51) insufflation group (UMIN-CTR, number: UMIN000018801). The post-procedural abdominal discomfort and the clinical relapse (partial Mayo score ≥ 3) rate within 8 weeks were evaluated.

RESULTS

Baseline backgrounds did not differ between the groups. The mean abdominal fullness and pain scores were significantly lower in the CO2 group than in the Air group immediately (p = 0.0003, p = 0.0003) and 30 min (p < 0.0001, p < 0.0001) after colonoscopy. While the overall clinical relapse rate remained unchanged between the groups, the clinical relapse rate at 8 weeks after colonoscopy was significantly lower in the CO2 group than in the Air group in patients not in complete remission (Mayo endoscopic subscore ≥ 1, p = 0.049; or partial Mayo score ≥ 1, p = 0.022).

CONCLUSIONS

CO2 insufflation can reduce abdominal discomfort in remissive patients with ulcerative colitis and decrease clinical relapse at 8 weeks after colonoscopy for those not in complete remission.

Efficacy and safety analysis of midazolam combined with dezocine sedation and analgesia colonoscopy in patients with inflammatory bowel disease: a prospective single-center open study

Objective: Colonoscopy plays an important role in the diagnosis, prognosis prediction, assessment of disease activity and severity, and treatment of inflammatory bowel disease (IBD)-related complications. However, some patients refuse to undergo colonoscopy due to perceived pain and other discomfort, their diagnosis and treatment are affected. Therefore, we conducted a prospective study to explore the efficacy and safety of midazolam combined with dezocine for sedation in IBD patients undergoing colonoscopy. Methods: 224 patients were divided into sedative-colonoscopy-group (SCG, n = 93), anesthesia-colonoscopy-group (ACG, n = 90) and ordinary-colonoscopy-group (OCG, n = 41). The vital signs (blood pressure, pulse, respiration and blood oxygen saturation), pain degree during colonoscopy, satisfaction and complication rates of the three groups were compared. Results: Before colonoscopy, there was no significant difference among the vital signs of the three groups. The vital signs of the ACG were significantly lower than those of the SEG and the OCG (p < 0.05), and the difference was not significant between the SCG and OCG during colonoscopy. The colonoscopy pain score in the SCG was lower than that in the OCG (0.79 ± 1.09 vs. 2.98 ± 1.27, p < 0.001). The satisfaction score of the SCG (9.26 ± 1.16) was not significantly different from that of the ACG (9.42 ± 1.41) but was higher than that of the OCG (6.63 ± 1.13) (p < 0.001). The total complication rate of the ACG was 45.56% (41/90), which was significantly higher than that of the SCG [20.43% (19/93)] and the OCG [19.51% (8/41)]. Colon perforation, abnormal blood pressure fluctuation and hypoxemia were significantly more common in the ACG than in the SCG and the OCG (p < 0.05). However, there was no significant difference in the incidence of complications between the SCG and OCG. Conclusion: Compared with ordinary-colonoscopy, colonoscopy performed under midazolam and dezocine sedation is more comfortable for patients, thereby increasing satisfaction and compliance. Colonoscopy that is performed under midazolam and dezocine is similar to colonoscopy that is anesthesia with propofol in terms of comfort, satisfaction and compliance and similar to ordinary-colonoscopy in terms of safety. Considering the shortage of anesthesiologists, the application of midazolam combined with dezocine for digestive endoscopy is worthy of clinical promotion.

Clinical Utility of the Neutrophil-to-Bilirubin Ratio in the Detection of Disease Activity in Ulcerative Colitis

Background

Ulcerative colitis (UC) is a chronic relapsing remitting form of inflammatory bowel disease (IBD). Current disease monitoring includes evaluation of symptoms, fecal calprotectin, and colonoscopy. Due to limited availability of the latter two modalities in China, we sought a readily available, inexpensive, disease monitoring laboratory assessment. We recently identified a novel serological index (the neutrophil-to-bilirubin ratio, NBR) for monitoring disease activity in Crohn's disease. However, the clinical significance has not been evaluated in UC. Here, we aimed to verify the hypothesis that NBR might be useful in monitoring clinical and endoscopic activity in patients with UC.

Methods

To test our hypothesis, we conducted a single-center, retrospective study including a total of 188 patients with UC and 145 non-IBD controls. NBR was calculated to determine its practical value in monitoring disease activity (including clinical and endoscopic activity). Disease activity of UC was determined by the partial Mayo score and the Mayo endoscopic score (MES) system.

Results

NBR was significantly higher in patients with UC than that in controls (12.10, IQR: 9.85-16.69 versus 5.06, IQR: 3.94-6.55; p < 0.001) and showed positive correlations with clinical and endoscopic disease activity in UC. Additionally, NBR was significantly lower in patients with endoscopic mucosal healing (MH) than that in those without endoscopic MH (8.81, IQR: 6.67-11.67 versus 13.51, IQR: 11.04-18.71; p < 0.001). Serial evaluation of NBR in a subset of patients demonstrated that NBR was significantly decreased during the MH stage compared with that during the endoscopically active stage.

Conclusion

Our study suggests that NBR may be a promising candidate for assessing disease activity in UC, with potential for widespread clinical use and significant clinical implications.

Principles, Preparation, Indications, Precaution, and Damage Control of Endoscopic Therapy in Inflammatory Bowel Disease

Interventional inflammatory bowel disease (IBD) or endoscopic therapy for IBD or IBD surgery-associated complications has emerged as a main treatment modality bridging medical and surgical treatment. It delivers therapy more definitive than medical therapy and less invasive than surgical treatment. The main applications of interventional IBD are strictures, fistulas, abscesses, bleeding, foreign bodies, postoperative complications, and colitis-associated neoplasia. The major endoscopic treatment modalities are balloon dilation, stricturotomy, strictureplasty, fistulotomy, sinusotomy, septectomy, banding ligation, incision and drainage, polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection.

Yield and Predictors of Surveillance Colonoscopies in Older Adults With Long-standing Ulcerative Colitis

BACKGROUND & AIMS

Although colonoscopies for dysplasia surveillance are standard of care in patients with long-standing ulcerative colitis (UC), there is a paucity of data on the yield of surveillance colonoscopies in those older than 75 years of age.

METHODS

We conducted a multicenter retrospective cohort study including patients with UC who underwent ≥1 colonoscopy at age ≥75 years. The primary outcome was diagnosis of dysplasia (visible or random) and colorectal cancer. Multivariable regression adjusted for relevant confounders examined the predictors of polypoid or non-polypoid dysplasia or colorectal cancer.

RESULTS

The primary cohort included 211 patients with UC who underwent 635 colonoscopies after age ≥75 years. A total of 83 patients (39.3%) patients had dysplasia or cancer detected. Among colonoscopies, 123 (19.4%) identified visible dysplasia, 23 (3.6%) had random dysplasia (1 high-grade dysplasia found in each group, respectively), and 5 (0.8%) had colon cancer. In multivariable analysis, prior adenoma or colon cancer below age 75 tears (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.07-3.96), flat dysplasia before 75 years (OR, 2.78; 95% CI, 1.05-7.44), and older age (80-84 years (OR, 2.29; 95% CI, 1.20-4.38), ≥85 years (OR, 3.54; 95% CI, 1.27-9.82) were associated with detection of dysplasia or cancer. Only 1 patient was noted to have a procedure-related complication.

CONCLUSIONS

Patients with long-standing UC without prior dysplasia may have a low yield on continued endoscopic surveillance at age ≥75 years. A targeted approach to surveillance may be appropriate in older individuals with UC.

A Novel Neutrophil-Based Biomarker to Monitor Disease Activity and Predict Response to Infliximab Therapy in Patients With Ulcerative Colitis

Background

Ulcerative colitis (UC) is characterized by refractory and recurrent mucosal inflammation, leading to a substantial healthcare burden. Diagnostic biomarkers predicting disease activity and treatment response remain elusive. To evaluate the application value of a novel neutrophil-based index (the neutrophil-to-albumin ratio, NAR) as a novel diagnostic biomarker in patients with UC and a predictive marker for disease activity and response to infliximab (IFX) therapy.

Methods

Clinical characteristics and laboratory parameters of enrolled subjects (patients with UC and healthy controls) were retrieved from the electronic medical record database of our hospital. Serum cytokine and fecal calprotectin levels were measured by enzyme-linked immunosorbent assay (ELISA). Mucosal expression levels of inflammatory agents were measured by quantitative RT-PCR (qRT-PCR).

Results

We found that NAR, which had not yet been explored in UC, was significantly increased in patients with UC (n = 146) compared to that in controls (n = 133) (1.95 ± 0.41 vs. 1.41 ± 0.23, p < 0.0001). NAR showed a positive association with the disease activity and inflammatory load in patients with UC. Pre-treatment NAR was significantly lower in IFX responders than that in non-responders (2.18 ± 0.29 vs. 2.44 ± 0.21, p = 0.0118), showing a significant ability to discriminate initial responders from primary non-responders to IFX induction therapy (AUC = 0.7866, p = 0.0076). Moreover, pre-treatment NAR predicted postinduction serum IFX trough level.

Conclusion

Our study provides evidences to utilize NAR in the diagnosis, activity monitoring, and IFX response prediction in patients with UC.

Clinical Significance of Novel Neutrophil-Based Biomarkers in the Diagnosis and Prediction of Response to Infliximab Therapy in Crohn’s Disease

With the increasing incidence and prevalence, Crohn’s disease (CD) has become one of the most challenging diseases in both diagnosis and treatment of gastroenterology. Evaluation of the disease activity and mucosal healing guides clinical decisions regarding subsequent therapy for CD. In this study, we enrolled a total of 144 patients with CD and 239 healthy controls were enrolled. Clinical characteristics and laboratory parameters of enrolled subjects were retrieved from the electronic medical record database of our hospital. Serum cytokine levels were measured by enzyme-linked immunosorbent assay (ELISA). Mucosa expression levels of inflammatory agents were measured by quantitative RT-PCR (qRT-PCR). We identified two neutrophil-based indexes, the neutrophil-to-albumin ratio (NAR) and neutrophil-to-bilirubin ratio (NBR), both of which had not yet been explored in CD or UC. NAR and NBR were significantly increased in patients with CD compared to those in healthy controls, and both indexes showed significantly positive correlations with CD activity and inflammatory load. In note, NAR and NBR showed better performance than blood neutrophil percentage, serum albumin, or bilirubin alone in these scenarios. More importantly, both NAR and NBR discriminated CD patients who completely or partially responded to infliximab (IFX) induction therapy from those with primary non-response. Our observations suggest that NAR and NBR may serve as promising biomarkers in the diagnosis and prediction of response to IFX therapy in CD.

Management of Crohn's stricture: medical, endoscopic and surgical therapies

Patients with Crohn's disease are at high risk of presenting with or developing a bowel stricture during the course of their disease. The available therapeutic options to manage a symptomatic Crohn's stricture include medical therapy (mainly biologics), surgical resection and endoscopic interventions. The choice of therapeutic modality depends on the clinical presentation of the stricture, the nature of the stricture (inflammatory vs fibrotic, primary vs anastomotic) and its anatomical characteristics on endoscopy and imaging (length, number, location of strictures and severity of obstruction). The aim herein is to provide an overview of the comprehensive assessment of a Crohn's stricture and to review the indications of the different therapeutic modalities, their success rates and their limitations to help clinicians properly evaluate and manage Crohn's strictures.

Serum Immune-Inflammation Index Assessment in the Patients with Ulcerative Colitis

Radiologic and endoscopic diagnostic methods are used to determine disease activity in ulcerative colitis (UC). In order for endoscopic procedures to be invasive and to prevent radiation exposure, especially in young people, studies have been carried out frequently to determine a simple, fast, and reliable activity marker with laboratory methods. Our aim in this study is to determine the usefulness of serum immune-inflammatory index as a noninvasive marker of activation in patients with ulcerative colitis. A total of 82 consecutive patients treated with a diagnosis of ulcerative colitis were included in the study. The disease activation was assessed using the Mayo endoscopic subscore. The site of involvement was grouped into two as left colitis and extensive colitis. Patients were divided into two groups as those who had active disease based on clinical and endoscopic findings and those who were in remission. C-reactive protein (CRP) levels, platelets, neutrophils, and lymphocytes were recorded in all participants. The systemic immune-inflammation index (SII) and CRP values were compared between UC patients with active disease or remission. The correlations between CRP, SII, and Mayo endoscopic subscores were analyzed. In addition, ROC curve analysis for SII was performed to determine the cut-off value, sensitivity, and specificity in determining ulcerative colitis activity. The value of SII was significantly higher in the active group than the remission group (respectively, 1497 ± 1300 and 495 ± 224, p < 0.001). In the correlation analysis, a significant correlation was found between SII and Mayo subscore. In ROC curve analysis, SII was found to be significantly effective in determining activity in ulcerative colitis patients. For 0.860 area under the curve, the sensitivity was 68.1% and the specificity was 91.2% at a cut-off value of 781.5. SII is significantly higher in patients with active ulcerative colitis than those in remission. It shows promise for use as a noninvasive marker of active ulcerative colitis.

Transmural Response and Transmural Healing Defined by Intestinal Ultrasound: New Potential Therapeutic Targets?

BACKGROUND AND AIMS

Intestinal ultrasound [IUS] is a useful modality to monitor patients with inflammatory bowel disease [IBD]. Little is known about the use of IUS and appropriate definitions for transmural response [TR] and healing [TH]. We aimed to establish the use of IUS in monitoring TH as a potential target in routine medical practice.

METHODS

Based on the prospective, non-interventional, multicentre studies TRUST and TRUST&UC, we conducted a post-hoc analysis of 351 IBD patients with increased bowel wall thickness [BWT]. We analysed the rates of patients achieving TR and TH, comparing three definitions of TH. In 137 Crohn's disease [CD] patients, the predictive value of TR and TH was investigated for the clinical and sonographic outcome at week 52.

RESULTS

Within 12 weeks of treatment intensification, 65.6% [n = 118] of CD patients and 76.6% [n = 131] of ulcerative colitis [UC] patients showed a TR. Depending on the definition, 23.9-37.2% [n = 58/67/43] of CD patients and 45.0-61.4% [n = 90/105/77] of UC patients had TH at week 12. CD patients with TH were more likely to reach clinical remission at week 12 (odds ratio [OR] 3.33 [1.09-10.2]; p = 0.044) and a favourable sonographic outcome (OR 5.59 [1.97-15.8]; p = 0.001) at week 52 compared with patients without TH.

CONCLUSIONS

IUS response and TH in a relevant proportion of patients suggests that IUS is a useful method to assess transmural inflammatory activity in daily clinical practice. TR and TH are predictive for the sonographic outcome at week 52.

Transabdominal Ultrasound and Magnetic Resonance Enterography in Inflammatory Bowel Disease: Results of an Observational Retrospective Single-Center Study

Purpose Transabdominal ultrasound (US) and magnetic resonance enterography (MRE) are used to assess disease activity and extent in IBD, but their impact on therapeutic decisions is unclear. Therefore, our study has two goals: to compare the usefulness of US and MRE in assessing disease extent and activity in the small and large bowel, and to determine the relevance for clinical decisions in IBD.

Materials and Methods We included 54 IBD patients who had undergone both MRE and US within three months. We used the construct reference standard model to compare MRE and US for detecting inflammation and examined the impact on clinical decisions in IBD patients.

Results In 54 IBD patients (44 patients Crohn’s disease (CD), 5 ulcerative colitis (UC), 5 indeterminate colitis (IC)), 42 patients (77.8%) showed inflammation either in the small or large bowel. Small bowel disease was present in 34 patients (77.3%). Complications were found in 19 patients (35.2%). MRE and US both showed high sensitivity (90.5 and 88.1%) and moderate specificity (50% in MRE and US) for detecting inflammation. MRE revealed higher sensitivity than US for detecting conglomerate tumors without statistical significance (85.7 vs. 71.4%, p=1.0) and equal specificity (97.9 vs 97.7, p=1.0). Therapeutic decisions included steroids in 20 patients (47.6%) and surgery/percutaneous drainage in six patients (14.3%), these decisions were triggered by results of US or MRE in equal distribution.

Conclusion US and MRE have comparable sensitivity and specificity for detecting intestinal inflammation and complications in IBD patients. Therefore, both methods are sufficient for making clinical decisions.

Role of Biomarkers in the Diagnosis and Treatment of Inflammatory Bowel Disease

The number of patients with inflammatory bowel disease (IBD) is increasing worldwide. Endoscopy is the gold standard to assess the condition of IBD. The problem with this procedure is that the burden and cost on the patient are high. Therefore, the identification of a reliable biomarker to replace endoscopy is desired. Biomarkers are used in various situations such as diagnosis of IBD, evaluation of disease activity, prediction of therapeutic effect, and prediction of relapse. C-reactive protein and fecal calprotectin have a lot of evidence as objective biomarkers of disease activity in IBD. The usefulness of the fecal immunochemical test, serum leucine-rich glycoprotein, and urinary prostaglandin E major metabolite have also been reported. Herein, we comprehensively review the usefulness and limitations of biomarkers that can be used in daily clinical practice regarding IBD. To date, no biomarker is sufficiently accurate to replace endoscopy; however, it is important to understand the characteristics of each biomarker and use the appropriate biomarker at the right time in daily clinical practice.

Thoughts on factors related to colonoscopy quality

With the increase in health consciousness and the prevalence of early gastrointestinal cancer screening, the number of diagnosed cases of colorectal polyps and adenomas in the Chinese general population has substantially increased. However, the overall adenoma detection rate (ADR) in China remains lower than the global standard of 30%. High quality colonoscopy is pivotal for increasing the ADR and reducing the risk of interval colon cancer. A few factors are related to the quality of colonoscopy, including preoperative evaluation of examinees, bowel preparation, techniques for intubation, use of image enhancement endoscopy, withdraw time, and prevention of adverse events.

Understanding Determinants of Patient Preferences Between Stool Tests and Colonoscopy for the Assessment of Disease Activity in Inflammatory Bowel Disease

BACKGROUND AND AIMS

Evidence is now available in support of using fecal biomarkers to monitor disease activity in inflammatory bowel disease (IBD). Patient adherence is often cited as a barrier to implementation. We assessed patient determinants for using stool tests to monitor disease activity.

METHODS

Prospective interview of IBD patients using an analytic hierarchy matrix survey built to understand preferences for choosing between stool testing or colonoscopy for monitoring disease activity, after considering different test criteria (accuracy, preparation, pain, complications). Theoretical thresholds of misclassification were posed to patients to see how they might consider shifting from colonoscopy to stool testing.

RESULTS

A total of 100 patients (n = 51 CD, n = 46 male) were interviewed with median age and disease duration of 44 years (IQR 27-63) and 9 years (IQR 5-21), respectively. Stool-based testing was preferred over colonoscopy by 60% initially; however, a majority of participants changed their choice to colonoscopy after learning more about the diagnostic performance of currently available stool tests for disease monitoring (p < 0.001). Across all sub-groups, accuracy was ranked as the top criterion when choosing between stool-based testing and colonoscopy for disease activity assessments. Most patients were willing to choose stool-based testing over colonoscopy for disease monitoring if the stool test was wrong at most 1 in 20 times (5% misclassification rate).

DISCUSSION

Accuracy is the most important criteria for IBD patients when choosing monitoring strategies, and a high degree of confidence is required of stool test results for patients to choose this strategy.

Panenteric capsule endoscopy versus ileocolonoscopy plus magnetic resonance enterography in Crohn's disease: a multicentre, prospective study

INTRODUCTION

Crohn's disease diagnosis and monitoring remains a great clinical challenge and often requires multiple testing modalities. Assessing Crohn's disease activity in the entire gastrointestinal (GI) tract using a panenteric capsule endoscopy (CE) system could be used as an alternative to colonoscopy and cross-sectional imaging. This study assessed the accuracy and safety of panenteric CE in Crohn's disease as compared with ileocolonoscopy (IC) and/or magnetic resonance enterography (MRE).

METHODS

A prospective, multicentre study was performed in subjects with established Crohn's disease. Individuals with proven small bowel patency underwent a standardised bowel preparation, followed by CE ingestion and IC either the same or following day. MRE, IC, and CE interpretations were performed by blinded central readers using validated scoring systems. The primary endpoint was the overall sensitivity of CE vs MRE and/or IC in Crohn's disease subjects.

RESULTS

Study enrolment included 158 subjects from 21 sites in the USA, Austria, and Israel. Of those, 99 were included in the analysis. Imaging modality scores indicated none to mild inflammation in the proximal small bowel and colon, but discrepant levels of inflammation in the terminal ileum. Overall sensitivity for active enteric inflammation (CE vs MRE and/or IC) was 94% vs 100% (p=0.125) and specificity was 74% vs 22% (p=0.001). Sensitivity of CE was superior to MRE for enteric inflammation in the proximal small bowel (97% vs 71%, p=0.021), and similar to MRE and/or IC in the terminal ileum and colon (p=0.500-0.625). There were seven serious adverse advents of which three were related to the CE device.

CONCLUSION

Panenteric CE is a reliable tool for assessing Crohn's disease mucosal activity and extent compared with more invasive methods. This study demonstrates high performance of the panenteric CE as compared to MRE and/or IC without the need for multiple tests in non-stricturing Crohn's disease.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT03241368.

Microsimulation Model to Determine the Cost-Effectiveness of Treat-to-Target Strategies for Ulcerative Colitis

BACKGROUND & AIMS

Little is known about the cost effectiveness of endoscopy or biomarker-based treat to target monitoring of patients with ulcerative colitis (UC).

METHODS

We used a microsimulation model to identify the most cost effective treat to target monitoring strategy for patients with UC staring therapy with biologics or small molecule inhibitors. We assessed symptoms (rectal bleeding) alone, a combination of symptoms and a biomarker (fecal calprotectin), and endoscopy. Transition probabilities, costs, and quality-adjusted life year (QALY) estimates were derived from published estimates. The microsimulation model tracked an individual patient's disease course and treatment exposures to modify downstream treatment effectiveness, probabilities, and disease outcomes. The primary analysis included 100,000 individuals over 5 years with a willingness to pay threshold of $100,000/QALY. Probabilistic sensitivity analyses were performed with 500 samples and 250 trials, in addition to multiple 1-, 2-, and 3-way microsimulation sensitivity analyses.

RESULTS

A total of 32 treatment sequencing algorithms were modeled alongside 3 disease monitoring strategies within a treat to target approach for UC. Combination symptom and biomarker-based monitoring resulted in the highest QALY estimate among all the treatment sequencing algorithms. However, monitoring disease activity with symptoms alone was the most cost-effective strategy in 86% of scenarios, followed by combination symptom and biomarker monitoring in 9%, and endoscopy monitoring in 5%. Results were sensitive to treatment costs, patient willingness to consider colectomy as a treatment option, and endoscopy costs. Endoscopy-based monitoring was favored when treatment costs were high and patients were unwilling to undergo colectomy.

CONCLUSIONS

The combination symptom and biomarker-based monitoring resulted in the highest QALY estimate. However, symptom-based monitoring is the most cost-effective approach to implementing treat to target monitoring for patients with UC receiving biologics and small molecule inhibitors.

Surrogate markers of mucosal healing in inflammatory bowel disease: A systematic review

BACKGROUND

Mucosal healing (MH) has emerged as a key therapeutic target in inflammatory bowel disease (IBD), and achievement of this goal is documented by endoscopy with biopsy. However, colonoscopy is burdensome and invasive, and substitution with an accurate noninvasive biomarker is desirable.

AIM

To summarize published data regarding the performance of noninvasive biomarkers in assessing MH in IBD patients.

METHODS

We conducted a systematic review of studies that reported the performance of biomarkers in diagnosing MH in patients with IBD. The main outcome measure was to review the diagnostic accuracy of serum and fecal markers that showed promising utility in assessing MH.

RESULTS

We screened 1301 articles, retrieved 46 manuscripts and included 23 articles for full-text analysis. The majority of the included manuscripts referred to fecal markers (12/23), followed by circulatory markers (8/23); only 3/23 of the included manuscripts investigated combined markers (serum and/or fecal markers). Fecal calprotectin (FC) was the most investigated fecal marker for assessing MH. In ulcerative colitis, for cutoff levels ranging between 58 mcg/g and 490 mcg/g, the sensitivity was 89.7%-100% and the specificity was 62%-93.3%. For Crohn’s disease, the cutoff levels of FC ranged from 71 mcg/g to 918 mcg/g (sensitivity 50%-95.9% and specificity 52.3%-100%). The best performance for a serum marker was observed for the endoscopic healing index, which showed a comparable accuracy to the measurement of FC and a higher accuracy than the measurement of serum C-reactive protein.

CONCLUSION

Several promising biomarkers of MH are emerging but cannot yet substitute for endoscopy with biopsy due to issues with reproducibility and standardization.

A Case of Tension Pneumothorax After Diverticular Rupture During Diagnostic Colonoscopy

Colonoscopy is routinely used for the diagnosis and treatment of colorectal diseases. Bowel perforation is a rare but severe complication that significantly increases the morbidity and mortality. Tension pneumothorax is an uncommon complication of colonic perforation. We present a case of the successful treatment of a patient with tension pneumothorax, following colonoscopy, by using tube thoracostomy and Hartman-type resection of the rectosigmoid junction and proximal sigmoid. Surgeons, anesthesiologists, and endoscopists should consider the possibility of pneumothorax as a rare complication of colonoscopy. Early detection and urgent treatment is the key to successful management.

What is the appropriate cut-off value of CRP to predict endoscopic remission in patients with ulcerative colitis in clinical remission?

PURPOSE

Noninvasive markers for predicting endoscopic remission (ER) in patients with ulcerative colitis (UC) who are in clinical remission (CR) are important for the determination of appropriate treatment modality. C-reactive protein (CRP) is a surrogate marker for assessing disease activity, albeit with a low sensitivity and specificity when the cut-off value is 0.3 or 0.5 mg/dL, which is usually considered normal. The CRP test has been improved, and even fine values within the normal range can be measured. The aim of this study was to determine the appropriate cut-off value of CRP below 0.3 mg/dL for the prediction of ER in UC patients with CR.

METHODS

A total of 132 patients who underwent endoscopic evaluation during CR were retrospectively reviewed. Clinical and endoscopic activity was measured using a simple clinical colitis activity index (SCCAI) and Mayo endoscopic subscore (MES). ER was defined as MES 0 or 1.

RESULTS

In UC patients in CR, the CRP level was significantly lower in ER (0.05, 0.03-2.57) vs. non-ER (0.14, 0.03-2.81) (p < 0.001). The CRP value predicted ER [area under the curve (AUC = 0.710)] with a sensitivity of 71.4% and a specificity of 71.7% at a cut-off value of 0.09 mg/dL. In contrast, the value of normal CRP (< 0.3 mg/dL) did not show sufficient predictive value (sensitivity, 27.3%; and specificity, 90.9%).

CONCLUSIONS

In UC patients in CR, it may be helpful to lower the CRP cut-off value that predict ER other than 0.3 mg/dL, which is usually considered normal.

Risks, time trends, and mortality of colonoscopy-induced perforation in hospitalized patients

BACKGROUND AND AIM

Colonic perforation is a rare complication of colonoscopy and ranges from 0% to 1% in all patients undergoing colonoscopy. The aim of this study was to assess the time trends, risk factors, and mortality associated with colonoscopy-induced perforation (CIP) in hospitalized patients as the data are limited.

METHODS

Data are obtained from the Nationwide Inpatient Sample database to identify hospitalized patients between 2005 and 2014 that had CIP. Various factors like age and gender were assessed for association with CIP, followed by univariate and multivariate regression analyses.

RESULTS

A total of 2 651 109 patients underwent inpatient colonoscopy between 2005 and 2014, and 4567 (0.2%) of the patients had CIP. Overall, incidence of CIP has increased from 2005 to 2014 (0.1% to 0.3%) (P < 0.001). On multivariate analysis, the adjusted odds ratio (OR) for CIP was highest in Caucasian race (OR: 1.49 [1.09, 2.06]), followed by after polypectomy, history of inflammatory bowel disease, end-stage renal disease, and age > 65 years (OR [95% CI] of 1.35 [1.23, 1.47], 1.34 [1.17, 1.53], 1.28 [1.02, 1.62], and 1.21 [1.11, 1.33], respectively) (all P < 0.05). CIP group had 33% less obesity (OR [95% CI]: 0.77 [0.65-0.9], P = 0.002) and 13-fold higher mortality (0.5% vs 8.1%) (P < 0.001) as compared to patients without CIP. The CIP-associated mortality ranged from 2% to 8% and remained stable throughout the study period.

CONCLUSIONS

Our study suggests that the risk of CIP was highest in elderly patients, Caucasians, those with inflammatory bowel disease, end-stage renal disease, and after polypectomy. Recognizing the factors associated with CIP may lead to informed discussion about risks and benefits of inpatient colonoscopy.

Muscularis propria detected at colonic biopsy is not a critical value

Perforation is a rare but potentially serious complication of cold forceps colonic biopsies. The presence of muscularis propria might portend increased risk of perforation and warrant urgent communication with endoscopists. However, identifying muscularis propria at time of biopsy is difficult for many reasons, including histologic overlap with muscularis mucosa. Incidental muscularis propria obtained in this manner has yet to be studied. Our objectives were to characterize the morphology of muscularis propria obtained incidentally via cold forceps colonic biopsies, establish practical criteria for diagnosing muscularis propria, and determine whether diagnosing muscularis propria correlates with perforation clinically. We retrospectively reviewed 3 specimens from nontargeted cold forceps colonic biopsies for which pieces of muscularis propria were presumed to be visualized based on larger size or lower nuclear density compared to the corresponding muscularis mucosa. These specimens were then compared to normal transmural control tissue from colectomy to confirm whether nuclear density or other features could distinguish muscularis propria from muscularis mucosa. Muscularis propria in the control tissue had lower nuclear density, smoother cytoplasmic texture, and more cytoplasmic pallor compared to the muscularis mucosa in the control tissue. This constellation of features was seen in all 3 specimens obtained via biopsy and therefore confirmed the presence of muscularis propria, though all patients lacked perforation clinically. Large size, low nuclear density, smooth cytoplasm, and pale cytoplasm identify objects as muscularis propria at time of colonic biopsy. The presence of muscularis propria fails to correlate with perforation clinically and does not warrant urgent communication.

The Impact of Hospital Teaching Status on Colonoscopy Perforation Risk: A National Inpatient Sample Study

Background

Colonoscopy has been widely used as a diagnostic tool for many conditions, including inflammatory bowel disease and colorectal cancer. Colonoscopy complications include perforation, hemorrhage, abdominal pain, as well as anesthesia risk. Although rare, perforation is the most dangerous complication that occurs in the immediate post-colonoscopy period with an estimated risk of less than 0.1%. Studies on colonoscopy perforation risk between teaching hospitals and non-teaching hospitals are scarce.

Methods

The National Inpatient Sample database was queried for patients who underwent inpatient colonoscopy between January 2010 and December 2014 in teaching versus non-teaching facilities in order to study their perforation rates. Our study population included 257,006 patients. Univariate regression was performed, and the positive results were analyzed using a multivariate regression module.

Results

Teaching hospitals had a higher risk of perforation (odds ratio 1.23, confidence interval 1.07 - 1.42, P = 0.004). Perforation rates were higher in females, patients with inflammatory bowel disease and dilatation of strictures. Polypectomy did not yield any statistical difference between the study groups. Other factors such as African-American ethnicity appeared to have a lower risk.

Conclusion

Perforation rates are higher in teaching hospitals. More studies are needed to examine the difference and how to mitigate the risks.

Practical guidelines on endoscopic treatment for Crohn's disease strictures: a consensus statement from the Global Interventional Inflammatory Bowel Disease Group

Stricture formation is a common complication of Crohn's disease, resulting from the disease process, surgery, or drugs. Endoscopic balloon dilation has an important role in the management of strictures, with emerging techniques, such as endoscopic electroincision and stenting, showing promising results. The underlying disease process, altered bowel anatomy from disease or surgery, and concurrent use of immunosuppressive drugs can make endoscopic procedures more challenging. There is an urgent need for the standardisation of endoscopic procedures and peri-procedural management strategies. On the basis of an extensive literature review and the clinical experience of the consensus group, which consisted of representatives from the Interventional Inflammatory Bowel Disease Group, we propose detailed guidance on all aspects of the principles and techniques for endoscopic procedures in the treatment of inflammatory bowel disease-associated strictures.

Clinical Impact of Sonographic Transmural Healing After Anti-TNF Antibody Treatment in Patients with Crohn's Disease

AIM

To assess the clinical benefits of transmural healing (TH) shown on intestinal ultrasound (IUS) after treatment with tumor necrosis factor-alpha antibodies (anti-TNF) in patients with Crohn's disease.

MATERIALS AND METHODS

This prospective study included consecutively 36 patients who underwent IUS in the week prior to start anti-TNF treatment, at 12 weeks, and 1 year after starting treatment. The clinical response to treatment was assessed using the Crohn's disease activity index and C-reactive protein (CRP) values. TH was defined as the normalization of bowel wall thickness on IUS. Treated patients were considered to have a good outcome if none of the following situations presented: need to reintroduce corticosteroids or intensify maintenance therapy and/or need for surgery.

RESULTS

After the induction regimen, 29 patients (80.6%) achieved clinical remission, and serum CRP values returned to normal in 20 patients (55.6%). In the IUS at 12 weeks, treatment induced a statistically significant reduction in the wall thickness (p < 0.001) and color Doppler grade (p < 0.001), as well as resolution of complications in 66.7% of patients (p < 0.03). IUS after 1 year of biological therapy showed TH in 14/33 patients (42.4%). During the follow-up (median 48.5 months), 23 of the 33 (69.7%) patients in remission or response after induction therapy presented a good outcome. Sonographic TH was significantly related with better outcomes, with only 1/14 patients having a poor outcome compared to 9/19 without TH (OR 11.7, 95% CI 1.2-108.2 p = 0.01, Chi-squared test).

CONCLUSION

Patients who achieve TH on IUS with biological treatment have better clinical outcomes.

A Comprehensive Review of the Diagnosis and Pharmacological Management of Crohn's Disease in the Elderly Population

Crohn's disease (CD) in the elderly is rising in prevalence, which is related to an increase in its incidence and improving life expectancies. There are differences in the presentation, natural history, and treatment of CD between adult-onset patients who progress to older age and patients who are initially diagnosed at an older age. Presentation at an older age may also delay or make diagnosis challenging due to accumulating co-morbidities that mimic inflammatory bowel disease. Differences exist between adult- and older-onset disease, yet many guidelines do not specifically distinguish the management of these two distinct populations. Identifying patients at high risk for progression or aggressive disease is particularly important as elderly patients may respond differently to medical and surgical treatment, and may be at higher risk for adverse effects. Despite newer agents being approved for CD, the data regarding efficacy and safety in the elderly are currently limited. Balancing symptom management with risks of medical and surgical therapy is an ongoing challenge and requires special consideration in these two distinct populations.

Adverse events related to colonoscopy: Global trends and future challenges

Colonoscopy is a widely used method for diagnosing and treating colonic disease. The number of colonoscopies is increasing worldwide, and concerns about associated adverse events are growing. Large-scale studies using big data for post-colonoscopy complications have been reported. A colon perforation is a severe complication with a relatively high mortality rate. The perforation rate, as reported in large studies (≥ 50,000 colonoscopies) published since 2000, ranges from 0.005-0.085%. The trend in the overall perforation rate in the past 15 years has not changed significantly. Bleeding is a more common adverse event than perforation. Recent large studies (≥ 50,000 colonoscopies) have reported post-colonoscopy bleeding occurring in 0.001-0.687% of cases. Most studies about adverse events related to colonoscopy were performed in the West, and relatively few studies have been conducted in the East. The incidence of post-colonoscopy complications increases in elderly patients or patients with inflammatory bowel diseases. It is important to use a unified definition and refined data to overcome the limitations of previous studies. In addition, a structured training program for endoscopists and a systematic national management program are needed to reduce post-colonoscopy complications. In this review, we discuss the current trends in colonoscopy related to adverse events, as well as the challenges to be addressed through future research.

How much force is required to perforate a colon during colonoscopy? An experimental study

INTRODUCTION

Colonoscopy is a commonly-performed procedure to diagnose pathology of the large intestine. Perforation of the colon is a rare but feared complication. It is currently unclear how much force is actually required to cause such injury nor how this is altered in certain diseases. Our aim was to analyze the forces required to perforate the colon in experiments using porcine tissues.

METHODS

Using 3D printing technology, models of two commercially available colonoscope heads were printed under three configurations: straight (I), 90°- bent (L) and fully bent (U). Samples of porcine colon were assessed with the models and configurations under perpendicular and angular load application and these data compared to the maximum force typically exerted by experienced colonoscopists.

RESULTS

The force required for perforation was significantly lower for the I compared to the L of the larger colonoscope head configuration under angular loading (14.1 vs. 46.5 N). Similar differences were found for linear stiffness when loaded (I vs. L small when loaded perpendicular: 0.8 vs. 2.4 N/mm, I vs. L large when loaded angled 0.7 vs. 2.1 N/mm). The mode and site of failure varied significantly between the scopes, with delamination of the mucosa/submucosa below the sample (96%) for the I, blunt mucosa/submucosa/muscularis failure adjacent to the loading site (77%) for the L, and failure of all colon layers lateral to the loading site (59%) for the U configuration, respectively. Perpendicular and angulated loading resulted in similar load-deformation values. Maximum forces typically exerted by colonoscopists averaged 13.9-27.9 N, depending on the colonoscope model and head configuration.

DISCUSSION

The force required for colon perforation varies depending on the type mode of loading and is likely lower than the force an experienced colonoscopist would exert in daily practice. There is a real risk of perforation, especially when the end of the scope is advancing directly into the colonic wall. The given experimental setup allowed to obtain reliable data of the colon in a standardized scenario, forming the basis for further experiments.

Management of iatrogenic perforation during colonoscopy in ulcerative colitis patients: a survey of gastroenterologists and colorectal surgeons

PURPOSE

Patients with ulcerative colitis, a high-risk group for the development of colon cancer, undergo colonoscopy more frequently than the general population. This increase in endoscopic evaluation also exposes these patients to an increased risk of complications, including iatrogenic perforation. Our survey study aims to determine factors that affect the management choices for iatrogenic perforations for ulcerative colitis patients in remission and identify areas of consensus among general gastroenterologists, inflammatory bowel disease specialists, and colorectal surgeons.

METHODS

An anonymous, cross-sectional survey was performed using an online platform. A matrix questionnaire posed five clinical scenarios with six management options for an iatrogenic perforation in ulcerative colitis patients with varying disease distribution, disease activity, and maintenance regimens.

RESULTS

One hundred thirty-eight general gastroenterologists, 35 inflammatory bowel disease specialists, and 174 colorectal surgeons responded to the survey; 47, 41, and 23%, respectively, answered they did not feel comfortable managing perforations in ulcerative colitis patients in remission. We found the greatest concordance among gastroenterologists and colorectal surgeons in cases of perforation in ulcerative colitis with a history of dysplasia; the majority of respondents chose staged total proctocolectomy with ileal pouch anal anastomosis. We found discordance in decision making for ulcerative colitis in remission without dysplasia, with perforation occurring in colitis involved and uninvolved areas.

CONCLUSION

Our survey revealed that a significant fraction of gastroenterologists and colorectal surgeons are uncomfortable managing iatrogenic colonic perforations in ulcerative colitis patients. We have identified knowledge and practice gaps in defining the optimal management of iatrogenic perforations in ulcerative colitis patients.

Does "July effect" exist in colonoscopies performed at teaching hospitals?

Background

To compare the outcomes of the colonoscopies between the early (July-September) and the later (April-June) academic year at the urban-teaching hospitals.

Methods

Our study cluster was derived from the National Inpatient Sample (NIS) database for the years 2010-2014. International Classification of Diseases, 9^th Revision, Clinical Modification (ICD-9 CM) procedure codes were used to identify the adult patients who underwent inpatient colonoscopy at urban-teaching hospitals. Post-colonoscopy outcomes and the complications were recognized using ICD-9 CM codes among any of the secondary diagnoses. Categorical and continuous variables were assessed using Pearson's Chi-square and Student's t-test respectively. Odds of complications during the early vs. later academic year was also evaluated by the two-way hierarchical logistic regression analysis.

Results

A total of 124,155 (weighted n=617,907) colonoscopy procedures were performed at the urban teaching hospitals in the US from 2010 to 2014. Out of these, 61,272 (weighted n=304,946) and 62,883 (weighted n=312,961) procedures were performed during early (July to September) and later (April to June) academic months, respectively. There was no significant difference in the all-cause mortality (1.4% vs. 1.4%, P=0.208), and the complications such as colonic perforations (3.1% vs. 3.2%, P=0.229) and postoperative infections (0.6% vs. 0.6%, P=0.733) between the two groups. Similarly, the splenic rupture (0.0% vs. 0.0%, P=0.180) was equally infrequent in both the groups. Bleeding/hematoma following colonoscopy (0.9% vs. 0.8%, P=0.004) was marginally higher during the later academic months. There were no statistically distinctions in terms of length of stay (LOS) (days) (7.3±9.1 vs. 7.3±9.1, P=0.918), total hospitalization charges ($60,549.41 vs. $59,918.56, P=0.311) and discharge of patients to other facilities between the early and the later academic months. Colonoscopy performed during the early academic months was not found to be a significant independent predictor for post-colonoscopy complications such as colon perforation (OR =0.99, 95% CI: 0.93-1.06, P=0.760), postoperative bleeding/hematoma (OR =0.92, 95% CI: 0.81-1.04, P=0.196) and postoperative infection (OR =0.99, 95% CI: 0.84-1.15, P=0.850).

Conclusions

There was no "July effect" on the outcomes of colonoscopies between the early vs. the later academic months.

Management of inflammatory bowel disease in older persons: evolving paradigms

The incidence and prevalence of inflammatory bowel disease (IBD) is increasing, and considering the aging population, this number is set to increase further in the future. The clinical features and natural history of elderly-onset IBD have many similarities with those of IBD in younger patients, but with significant differences including a broader differential diagnosis. The relative lack of data specific to elderly patients with IBD, often stemming from their typical exclusion from clinical trials, has made clinical decision-making somewhat challenging. Treatment decisions in elderly patients with IBD must take into account age-specific concerns such as comorbidities, locomotor and cognitive function, and polypharmacy, to set realistic treatment targets in order to enable personalized treatment and minimize harm. Notwithstanding paucity of clinical data, recent studies have provided valuable insights, which, taken together with information gleaned from previous studies, can broaden our understanding of IBD. These insights may contribute to the development of paradigms for the holistic and, when possible, evidence-based management of this potentially vulnerable population and are the focus of this review.

Exploring endoscopic therapy for the treatment of Crohn's disease-related fistula and abscess

Fistula and abscess represent penetrating disease phenotypes of Crohn's disease (CD) and can develop in patients with or without prior history of CD-related surgery. While CD fistula and abscess have been traditionally treated with medical and surgical therapy, the role of endoscopic therapy in this particular phenotype of CD is expanding recently, thanks to advanced endoscopic techniques and a better understanding of pathogenesis and natural history of the disease and principle of treatment. The success of endoscopic treatment for inflammatory bowel disease depends on comprehension and appreciation of principles, then techniques, followed by instrument and device. Attempts should be made to temporarily or permanently close the feeding side (or the primary) orifice at the gut, by various forms of clipping. Endoscopic fistulotomy is feasible, particularly for perianal fistula and surgery-associated distal bowel fistula. Perianal abscess can be treated with endoscopic incision and drainage and even seton placement. Endoscopic treatment for fistula and abscess as well as for stricture has become an important part of the multidisciplinary approach to complex CD.

European Crohn's and Colitis Organisation Topical Review on IBD in the Elderly

This ECCO topical review of the European Crohn's and Colitis Organisation [ECCO] focuses on the epidemiology, pathophysiology, diagnosis, management and outcome of the two most common forms of inflammatory bowel disease, Crohn's disease and ulcerative colitis, in elderly patients. The objective was to reach expert consensus to provide evidence-based guidance for clinical practice.

Systematic review: Safety of balloon assisted enteroscopy in Crohn's disease

AIM

To determine the overall and comparative risk of procedure related perforation of balloon assisted enteroscopy (BAE) in Crohn's disease (CD).

METHODS

Systematic review (PROSPERO #CRD42015016381) of studies reporting on CD patients undergoing BAE. Seventy-three studies reporting on 1812 patients undergoing 2340 BAEs were included. Primary outcome of interest was the overall and comparative risk of procedure related perforation of diagnostic BAE in CD. Secondary outcomes of interest were risk of procedure related perforation of diagnostic double balloon enteroscopy (DBE), risk of procedure related perforation of therapeutic BAE, efficacy of stricture dilation, and clinical utility of endoscopically assessing small bowel disease activity.

RESULTS

Per procedure perforation rate of diagnostic BAE in CD was 0.15% (95%CI: 0.05-0.45), which was similar to diagnostic BAE for all indications (0.11%; IRR = 1.41, 95%CI: 0.28-4.50). Per procedure perforation rate of diagnostic DBE in CD was 0.12% (95%CI: 0.03-0.44), which was similar to diagnostic DBE for all indications (0.22%; IRR = 0.54, 95%CI: 0.06-0.24). Per procedure perforation rate of therapeutic BAE in CD was 1.74% (95%CI: 0.85-3.55). Eighty-six percent of therapeutic perforations were secondary to stricture dilation. Dilation was attempted in 207 patients and 30% required surgery during median follow-up of 18 months. When diagnostic BAE assessed small bowel disease activity, changes in medical therapy resulted in endoscopic improvement in 77% of patients.

CONCLUSION

Diagnostic BAE in CD has a similar rate of perforation as diagnostic BAE for all indications and can be safely performed in assessment of mucosal healing.

Endoscopy in the Diagnosis and Management of Complications of Inflammatory Bowel Disease

The role of endoscopy in inflammatory bowel disease (IBD) has grown over the last decade in both diagnostic and therapeutic realms. It aids in the initial diagnosis of the disease and also in the assessment of the extent and severity of disease. IBD is associated with development of multiple complications such as strictures, fistulae, and colon cancers. Endoscopy plays a pivotal role in the diagnosis of colon cancer in patients with IBD through incorporation of chromoendoscopy for surveillance. In addition, endoscopic resection with surveillance is recommended in the management of polypoid dysplastic lesions without flat dysplasia. IBD-associated benign strictures with obstructive symptoms amenable to endoscopic intervention can be managed with endoscopic balloon dilation both in the colon and small intestine. In addition, endoscopy plays a major role in assessing the neoterminal ileum after surgery to risk-stratify patients after ileocolonic resection and assessment of a patient with ileoanal pouch anastomosis surgery and management of postsurgical complications. Our article summarizes the current evidence in the role of endoscopy in the diagnosis and management of complications of IBD.

Elderly patients and inflammatory bowel disease

The incidence and prevalence of inflammatory bowel disease (IBD) is increasing globally. Coupled with an ageing population, the number of older patients with IBD is set to increase. The clinical features and therapeutic options in young and elderly patients are comparable but there are some significant differences. The wide differential diagnosis of IBD in elderly patients may result in a delay in diagnosis. The relative dearth of data specific to elderly IBD patients often resulting from their exclusion from pivotal clinical trials and the lack of consensus guidelines have made clinical decisions somewhat challenging. In addition, age specific concerns such as co-morbidity; loco-motor and cognitive function, poly-pharmacy and its consequences need to be taken into account. In applying modern treatment paradigms to the elderly, the clinician must consider the potential for more pronounced adverse effects in this vulnerable group and set appropriate boundaries maximising benefit and minimising harm. Meanwhile, clinicians need to make personalised decisions but as evidence based as possible in the holistic, considered and optimal management of IBD in elderly patients. In this review we will cover the clinical features and therapeutic options of IBD in the elderly; as well as addressing common questions and challenges posed by its management.

Endoscopic Therapy in Inflammatory Bowel Diseases

Background

Endoscopy is an essential diagnostic and therapeutic modality in the clinical care of inflammatory bowel disease (IBD) patients. Endoscopic therapy can be used for treatment of disease-related strictures, surveillance and resection of intraepithelial neoplasia, and treatment of fistulas or disease-related complications, and is currently being evaluated regarding its capacity in in vivo molecular imaging procedures.

Methods

A literature search using Medline and Science Citation Index was performed in March 2015. All studies on endoscopic therapy in IBD published from 1980 to 2015 (March) were reviewed. Potential studies were initially screened by title and abstract. The terms ‘endoscopy IBD’, ‘endoscopy therapy IBD’, ‘dilatation IBD’, ‘strictureplasty Crohn's disease’, ‘endoscopy therapy fistula’, ‘endoscopy toxic megacolon’, ‘endoscopy dysplasia IBD’, ‘endoscopy complications IBD’, and ‘molecular imaging IBD’ were used in the search. A total of 115 articles were studied to construct this review.

Results

Dilatation is most useful in short anastomotic strictures, but can be also undertaken in colonic strictures. Strictures in ulcerative colitis are always suspicious for neoplasia and should be evaluated carefully. Lesions with intraepithelial neoplasia can be resected when complete removal can be assured. The finding of carcinoma or high-grade dysplasia in a random biopsy is an indication for colectomy. If intraepithelial neoplasia is present in random biopsy specimens, colectomy should similarly be recommended. Endoscopic therapy of Crohn's fistulas is a possible emerging technology. In vivo molecular imaging is currently being studied in IBD patients and offers promising therapeutic opportunities.

Conclusion

Therapeutic endoscopy is indispensable in the management of IBD. It has to be carefully evaluated against alternative surgical options but often offers an effective therapeutic approach.

© 2015 S. Karger GmbH, Freiburg

Endoscopic Therapy in Crohn's Disease: Principle, Preparation, and Technique

Stricture and fistula are common complications of Crohn's disease. Endoscopic balloon dilation and needle-knife stricturotomy has become a valid treatment option for Crohn's disease-associated strictures. Endoscopic therapy is also increasingly used in Crohn's disease-associated fistula. Preprocedural preparations, including routine laboratory testing, imaging examination, anticoagulant management, bowel cleansing and proper sedation, are essential to ensure a successful and safe endoscopic therapy. Adverse events, such as perforation and excessive bleeding, may occur during endoscopic intervention. The endoscopist should be well trained, always be cautious, anticipate for possible procedure-associated complications, be prepared for damage control during endoscopy, and have surgical backup ready. In this review, we discuss the principle, preparation, techniques of endoscopic therapy, as well as the prevention and management of endoscopic procedure-associated complications. We propose that inflammatory bowel disease endoscopy may be a part of training for "super" gastroenterology fellows, i.e., those seeking a career in advanced endoscopy or in inflammatory bowel disease.

Therapeutic Armamentarium for Stricturing Crohn's Disease: Medical Versus Endoscopic Versus Surgical Approaches

One-third of patients with Crohn's disease (CD) present as stricturing phenotype characterized by progressive luminal narrowing and obstructive symptoms. The diagnosis and management of these patients have been intriguing and challenging. Immunomodulators and biologics have been successfully used in treating inflammatory and fistulizing CD. There are issues of efficacy and safety of biological agents in treating strictures in CD. Rapid mucosal healing from potent biological agents may predispose patients to the development of new strictures or worsening of existing strictures. On the other hand, strictures constitute one-fifth of the reasons for surgery in patients with CD. Disease recurrence is common at or proximal to the anastomotic site with the majority of these patients developing new endoscopic lesions within 1 year of surgery. The progressive nature of the disease with repetitive cycle of inflammation and stricture formation results in repeated surgery, with a risk of small bowel syndrome. There is considerable quest for bowel conserving endoscopic and surgical strategies. Endoscopic balloon dilation and stricturoplasty have emerged as valid alternatives to resection. Endoscopic balloon dilation has been shown to be feasible, safe, and effective for the short primary or anastomotic strictures. However, repeated dilations are often needed, and long-term outcomes of endoscopic balloon dilation remain to be investigated. The introduction of stricturoplasty has added another dimension to bowel saving strategy. Although postoperative recurrence rate after stricturoplasty is comparable with surgical resection, there are concerns for increased risk of malignancy in preserved bowel. Laparoscopic surgery has widely been performed with similar outcomes to open approach with fewer complications, quicker recovery, better cosmesis, and lower cost. All of these issues should be considered by physicians involved in the management of patients with stricturing CD.

Obtaining research biopsies during pediatric colonoscopy: Safety and adverse events

AIM: To investigate the safety profile of acquiring additional intestinal biopsies for research purposes in children undergoing a medically indicated colonoscopy.

METHODS: A retrospective review of 122 pediatric patients who underwent colonoscopy over a 9 mo time period was completed. 38/122 participants consented to a research study in which 4 additional biopsies were obtained, in addition to routine biopsies. The outcomes after colonoscopy were measured in the research participants, and compared to 84 control participants who did not consent for the study. Groups were compared with regard to number of biopsies obtained, underlying diagnosis, and both serious and minor adverse outcomes. Data was collected including: age, gender, race, indication, diagnosis, number of biopsies obtained per case and post procedure adverse events. Medical records were reviewed and a questionnaire was completed by each of the ten gastroenterologists who performed procedures during the study. Physicians were asked about individual patient outcomes to ensure that all adverse events, such as perforation, excessive bleeding, infection, and minor gastrointestinal outcomes, were captured and included.

RESULTS: The research group had more biopsies obtained (mean = 13.58 ± 4.21) compared to controls (mean = 9.33 ± 4.40), P≤ 0.0001, however there was no difference in adverse events. Serious outcomes, defined as perforation, bleeding and infection, did not occur, in either group. As such, the relationship between serious adverse events and number of biopsies obtained was not determined. Minor gastrointestinal outcomes, such as abdominal pain, diarrhea or vomiting, were reported in 21 patients (8 research participants and 13 control participants) however the incidence of minor gastrointestinal outcomes between the two groups did not vary significantly, P = 0.45. Additionally, the mean number of biopsies obtained in patients who had a minor outcome (mean = 12.1 ± 0.77), compared to those with no adverse outcome (mean = 10.34 ± 0.5), revealed no statistical difference between the groups (P = 0.12), suggesting that number of biopsies is not associated with incidence of minor adverse events.

CONCLUSION: Patients participating in research requiring acquisition of additional biopsies for research purposes alone, are not at an increased risk of adverse outcomes.