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Hirschfield GM, Arndtz K, Kirkham A, Chen YY, Fox R, Rowe A, Douglas-Pugh J, Thorburn D, Barnes E, Aithal GP, Hull D, Bhandal K, Olsen K, Woodward P, Lax S, Newsome P, Smith DJ, Kallio A, Adams DH, Homer V, Weston CJ. Vascular adhesion protein-1 blockade in primary sclerosing cholangitis: Open-label, multicenter, single-arm, phase II trial. Hepatol Commun 2024; 8:e0426. [PMID: 38668724 DOI: 10.1097/hc9.0000000000000426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/23/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND Primary sclerosing cholangitis is a progressive inflammatory liver disease characterized by biliary and liver fibrosis. Vascular adhesion protein-1 (VAP-1) is important in the inflammatory process driving liver fibrosis. We evaluated the safety and efficacy of VAP-1 blockade with a monoclonal antibody (timolumab, BTT1023) in patients with primary sclerosing cholangitis. METHODS BUTEO was a prospective, single-arm, open-label, multicenter, phase II trial, conducted in 6 centers in the United Kingdom. Patients with primary sclerosing cholangitis aged 18-75 years had an alkaline phosphatase value of >1.5 times the upper limit of normal. The dose-confirmatory stage aimed to confirm the safety of timolumab through the incidence of dose-limiting toxicity and sufficient trough levels of circulating antibody to block VAP-1 function. The primary outcome of the dose-expansion portion of the trial was patient's response to timolumab at day 99, as measured by a reduction in serum alkaline phosphatase by 25% or more from baseline to day 99. RESULTS Twenty-three patients were recruited: 7 into the initial dose-confirmatory stage and a further 16 into an expansion stage. Timolumab (8 mg/kg) was confirmed to be safe for the duration of administration with sufficient circulating levels. Only 2 of the 18 evaluable patients (11.1%) achieved a reduction in alkaline phosphatase levels of 25% or more, and both the proportion of circulating inflammatory cell populations and biomarkers of fibrosis remained unchanged from baseline. CONCLUSIONS The BUTEO trial confirmed 8 mg/kg timolumab had no short-term safety signals and resulted in sufficient circulating levels of VAP-1 blocking timolumab. However, the trial was stopped after an interim assessment due to a lack of efficacy as determined by no significant change in serum liver tests.
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Affiliation(s)
- Gideon M Hirschfield
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
- Division of Gastroenterology and Hepatology, Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Katherine Arndtz
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
| | - Amanda Kirkham
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Yung-Yi Chen
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
| | - Richard Fox
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Parexel International, Sheffield, UK
| | - Anna Rowe
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Jessica Douglas-Pugh
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Douglas Thorburn
- Liver Services, Royal Free London NHS Foundation Trust, London, UK
| | - Eleanor Barnes
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Guruprasad P Aithal
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, Faculty of Medicine and Health Sciences, The University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Nottingham, UK
| | - Diana Hull
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
| | - Khushpreet Bhandal
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
| | - Kathryn Olsen
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
| | - Paul Woodward
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
| | - Siân Lax
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Philip Newsome
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
| | | | | | - David H Adams
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
| | - Victoria Homer
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Chris J Weston
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
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Shafrir A, Katz LH, Shauly-Aharonov M, Zinger A, Safadi R, Stokar J, Kalisky I. Low ALT Is Associated with IBD and Disease Activity: Results from a Nationwide Study. J Clin Med 2024; 13:1869. [PMID: 38610634 PMCID: PMC11012492 DOI: 10.3390/jcm13071869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Sarcopenia is underdiagnosed in patients with inflammatory bowel disease (IBD). Low alanine transaminase (ALT) is associated with sarcopenia. We evaluated the association between low ALT and the presence of IBD and disease activity. Methods: Data were collected from a national Israeli health insurer cohort comprising 976,615 patients. Patients with a diagnosis of IBD were compared to healthy controls. After exclusion of patients with liver disease, ALT > 40 IU/L and age < 18, a total of 233,451 patients were included in the analysis. Low ALT was defined as <10 IU/L. Results: Low ALT was more common amongst patients with IBD than in healthy controls (7.76% vs. 5.7% p < 0.001). Low ALT was found in 148 (7.9%) of the patients with CD and 69 (6.9%) of the patients with UC. For CD, low ALT was associated with increased fecal calprotectin (FC) and CRP (223.00 μg/mg [63.45-631.50] vs. 98.50 [31.98-324.00], p < 0.001, 9.10 mg/L [3.22-19.32] vs. 3.20 [1.30-8.30], p < 0.001) and decreased albumin and hemoglobin (3.90 g/dL [3.60-4.20] vs. 4.30 [4.00-4.50], p < 0.001,12.20 g/dL [11.47-13.00] vs. 13.60 [12.60-14.70], p < 0.001). For UC, low ALT was associated with higher FC and CRP (226.50 μg/mg [143.00-537.00] vs. 107.00 [40.85-499.50], p = 0.057, 4.50 mg/L [1.90-11.62] vs. 2.30 [1.00-6.20], p < 0.001) and with lower albumin and hemoglobin (4.00 g/dL [3.62-4.18] vs. 4.30 [4.10-4.40], p < 0.001, 12.40 g/dL [11.60-13.20] vs. 13.60 [12.60-14.60], p < 0.001). These findings remained consistent following multivariate regression and in a propensity score-matched cohort. Conclusions: Low ALT is more common in patients with IBD and is associated with biochemical disease activity indices.
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Affiliation(s)
- Asher Shafrir
- Meuhedet Health Medical Organization, Jerusalem District, Tel Aviv 6203854, Israel
- Institute of Gastroenterology and Hepatology, Hadassah Medical Center, Jerusalem 1200, Israel; (L.H.K.); (A.Z.); (I.K.)
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190500, Israel; (R.S.); (J.S.)
| | - Lior H. Katz
- Institute of Gastroenterology and Hepatology, Hadassah Medical Center, Jerusalem 1200, Israel; (L.H.K.); (A.Z.); (I.K.)
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190500, Israel; (R.S.); (J.S.)
| | - Michal Shauly-Aharonov
- Braun School of Public Health and Community Medicine, Hebrew University of Jerusalem, Jerusalem 9190500, Israel;
- The Jerusalem College of Technology, Jerusalem 9190401, Israel
| | - Adar Zinger
- Institute of Gastroenterology and Hepatology, Hadassah Medical Center, Jerusalem 1200, Israel; (L.H.K.); (A.Z.); (I.K.)
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190500, Israel; (R.S.); (J.S.)
| | - Rifaat Safadi
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190500, Israel; (R.S.); (J.S.)
- The Liver Institute, Hadassah Medical Organization, Jerusalem 91120, Israel
| | - Joshua Stokar
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190500, Israel; (R.S.); (J.S.)
- Department of Endocrinology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190500, Israel
| | - Itay Kalisky
- Institute of Gastroenterology and Hepatology, Hadassah Medical Center, Jerusalem 1200, Israel; (L.H.K.); (A.Z.); (I.K.)
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190500, Israel; (R.S.); (J.S.)
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3
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Dunleavy KA, Santiago P, Forde G, Harmsen WS, McKenna NP, Coelho-Prabhu N, Shawki S, Raffals L. Total Proctocolectomy vs Subtotal/total Colectomy for Neoplasia in Patients With Inflammatory Bowel Disease and Primary Sclerosing Cholangitis. Inflamm Bowel Dis 2023:izad278. [PMID: 38142126 DOI: 10.1093/ibd/izad278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC) frequently undergo restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for medically refractory disease or colonic dysplasia/neoplasia. Subtotal colectomy with ileosigmoid or ileorectal anastomosis may have improved outcomes but is not well studied. Due to increased risk for colorectal cancer in PSC-IBD, there is hesitancy to perform subtotal colectomy. We aim to describe the frequency of colorectal dysplasia/neoplasia following IPAA vs subtotal colectomy in PSC-IBD patients. METHODS We completed a retrospective study from 1972 to 2022 of patients with PSC-IBD who had undergone total proctocolectomy with IPAA or subtotal colectomy. We abstracted demographics, disease characteristics, and endoscopic surveillance data from the EMR. RESULTS Of 125 patients (99 IPAA; 26 subtotal), the indication for surgery was rectal sparing medically refractory disease (51% vs 42%), dysplasia (37% vs 30%) and neoplasia (11% vs 26%) in IPAA vs subtotal colectomy patients, respectively. On endoscopic surveillance of IPAA patients, 2 (2%) had low-grade dysplasia (LGD) in the ileal pouch and 2 (2%) had LGD in the rectal cuff after an average of 8.4 years and 12.3 years of follow-up, respectively. One (1%) IPAA patient developed neoplasia of the rectal cuff after 17.8 years of surgical continuity. No subtotal colectomy patients had dysplasia/neoplasia in the residual colon or rectum. CONCLUSIONS In patients with PSC-IBD, there was no dysplasia or neoplasia in those who underwent subtotal colectomy as opposed to the IPAA group. Subtotal colectomy may be considered a viable surgical option in patients with rectal sparing PSC-IBD if adequate endoscopic surveillance is implemented.
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Affiliation(s)
- Katie Ann Dunleavy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Priscila Santiago
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Gerard Forde
- Department of Gastroenterology, Galway University Hospital, Galway, Ireland
| | - W Scott Harmsen
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | | | | | - Sherief Shawki
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Miyazu T, Ishida N, Asai Y, Tamura S, Tani S, Yamade M, Iwaizumi M, Hamaya Y, Osawa S, Baba S, Sugimoto K. Intrahepatic cholangiocarcinoma in patients with primary sclerosing cholangitis and ulcerative colitis: Two case reports. World J Gastrointest Surg 2023; 15:1224-1231. [PMID: 37405109 PMCID: PMC10315124 DOI: 10.4240/wjgs.v15.i6.1224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 03/10/2023] [Accepted: 04/12/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is an extraintestinal manifestation of ulcerative colitis (UC). PSC is a well-known risk factor for intrahepatic cholangiocarcinoma (ICC), and ICC is known to have a poor prognosis.
CASE SUMMARY We present two cases of ICC in patients with PSC associated with UC. In the first case, a tumor was found by magnetic resonance imaging (MRI) in the liver of a patient with PSC and UC who presented to our hospital with right-sided rib pain. The second patient was asymptomatic, but we unexpectedly detected two liver tumors in an MRI performed to evaluate bile duct stenosis associated with PSC. ICC was strongly suspected by computed tomography and MRI in both cases, and surgery was performed, but unfortunately, the first patient died of ICC recurrence 16 mo postoperatively, and the second patient died of liver failure 14 mo postoperatively.
CONCLUSION Careful follow-up of patients with UC and PSC with imaging and blood tests is necessary for early detection of ICC.
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Affiliation(s)
- Takahiro Miyazu
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Natsuki Ishida
- Department of Endoscopic and Photodynamic Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Yusuke Asai
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Satoshi Tamura
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Shinya Tani
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Mihoko Yamade
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Moriya Iwaizumi
- Department of Laboratory Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Yasushi Hamaya
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Satoshi Osawa
- Department of Endoscopic and Photodynamic Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Satoshi Baba
- Department of Diagnostic Pathology, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Ken Sugimoto
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
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Ichikawa M, Nakamoto N, Kredo-Russo S, Weinstock E, Weiner IN, Khabra E, Ben-Ishai N, Inbar D, Kowalsman N, Mordoch R, Nicenboim J, Golembo M, Zak N, Jablonska J, Sberro-Livnat H, Navok S, Buchshtab N, Suzuki T, Miyamoto K, Teratani T, Fujimori S, Aoto Y, Konda M, Hayashi N, Chu PS, Taniki N, Morikawa R, Kasuga R, Tabuchi T, Sugimoto S, Mikami Y, Shiota A, Bassan M, Kanai T. Bacteriophage therapy against pathological Klebsiella pneumoniae ameliorates the course of primary sclerosing cholangitis. Nat Commun 2023; 14:3261. [PMID: 37277351 DOI: 10.1038/s41467-023-39029-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 05/25/2023] [Indexed: 06/07/2023] Open
Abstract
Primary sclerosing cholangitis (PSC) is characterized by progressive biliary inflammation and fibrosis. Although gut commensals are associated with PSC, their causative roles and therapeutic strategies remain elusive. Here we detect abundant Klebsiella pneumoniae (Kp) and Enterococcus gallinarum in fecal samples from 45 PSC patients, regardless of intestinal complications. Carriers of both pathogens exhibit high disease activity and poor clinical outcomes. Colonization of PSC-derived Kp in specific pathogen-free (SPF) hepatobiliary injury-prone mice enhances hepatic Th17 cell responses and exacerbates liver injury through bacterial translocation to mesenteric lymph nodes. We developed a lytic phage cocktail that targets PSC-derived Kp with a sustained suppressive effect in vitro. Oral administration of the phage cocktail lowers Kp levels in Kp-colonized germ-free mice and SPF mice, without off-target dysbiosis. Furthermore, we demonstrate that oral and intravenous phage administration successfully suppresses Kp levels and attenuates liver inflammation and disease severity in hepatobiliary injury-prone SPF mice. These results collectively suggest that using a lytic phage cocktail shows promise for targeting Kp in PSC.
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Affiliation(s)
- Masataka Ichikawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Nobuhiro Nakamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Takahiro Suzuki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Kentaro Miyamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Toshiaki Teratani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Sota Fujimori
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Yoshimasa Aoto
- JSR-Keio University Medical and Chemical Innovation Center (JKiC), JSR Corp., Tokyo, Japan
| | - Mikiko Konda
- JSR-Keio University Medical and Chemical Innovation Center (JKiC), JSR Corp., Tokyo, Japan
| | - Naoki Hayashi
- JSR-Keio University Medical and Chemical Innovation Center (JKiC), JSR Corp., Tokyo, Japan
| | - Po-Sung Chu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Nobuhito Taniki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Rei Morikawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Ryosuke Kasuga
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Takaya Tabuchi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Shinya Sugimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Yohei Mikami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Atsushi Shiota
- Department of Microbiology and Immunology, Keio University, Tokyo, Japan
- Microbiopharm Japan, Co. Ltd., Tokyo, Japan
| | | | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Tokyo, Japan.
- Japan Agency for Medical Research and Development, AMED, Tokyo, Japan.
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Bowlus CL, Arrivé L, Bergquist A, Deneau M, Forman L, Ilyas SI, Lunsford KE, Martinez M, Sapisochin G, Shroff R, Tabibian JH, Assis DN. AASLD practice guidance on primary sclerosing cholangitis and cholangiocarcinoma. Hepatology 2023; 77:659-702. [PMID: 36083140 DOI: 10.1002/hep.32771] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 07/26/2022] [Indexed: 01/28/2023]
Affiliation(s)
- Christopher L Bowlus
- Division of Gastroenterology , University of California Davis Health , Sacramento , California , USA
| | | | - Annika Bergquist
- Karolinska Institutet , Karolinska University Hospital , Stockholm , Sweden
| | - Mark Deneau
- University of Utah , Salt Lake City , Utah , USA
| | - Lisa Forman
- University of Colorado , Aurora , Colorado , USA
| | - Sumera I Ilyas
- Mayo Clinic College of Medicine and Science , Rochester , Minnesota , USA
| | - Keri E Lunsford
- Rutgers University-New Jersey Medical School , Newark , New Jersey , USA
| | - Mercedes Martinez
- Vagelos College of Physicians and Surgeons , Columbia University , New York , New York , USA
| | | | | | - James H Tabibian
- David Geffen School of Medicine at UCLA , Los Angeles , California , USA
| | - David N Assis
- Yale School of Medicine , New Haven , Connecticut , USA
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Ficus pandurata Hance Inhibits Ulcerative Colitis and Colitis-Associated Secondary Liver Damage of Mice by Enhancing Antioxidation Activity. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:2617881. [PMID: 34966476 PMCID: PMC8710911 DOI: 10.1155/2021/2617881] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/06/2021] [Accepted: 11/10/2021] [Indexed: 12/11/2022]
Abstract
Inflammatory bowel disease (IBD), a global disease threatening human health, is commonly accompanied by secondary liver damage (SLD) mediated by the gut-liver axis. Oxidative stress acts a critical role in the onset of IBD, during which excessive oxidation would destroy the tight junctions between intestinal cells, promote proinflammatory factors to penetrate, and thereby damage the intestinal mucosa. Ficus pandurata Hance (FPH) is widely used for daily health care in South China. Our previous study showed that FPH protected acute liver damage induced by alcohol. However, there is no study reporting FPH treating ulcerative colitis (UC). This study is designed to investigate whether FPH could inhibit UC and reveal its potential mechanism. The results showed that FPH significantly alleviated the UC disease symptoms including the body weight loss, disease activity index (DAI), stool consistency changing, rectal bleeding, and colon length loss of UC mice induced by dextran sulfate sodium (DSS) and reversed the influences of DSS on myeloperoxidase (MPO) and diamine oxidase activity (DAO). FPH suppressed UC via inhibiting the TLR4/MyD88/NF-κB pathway and strengthened the gut barrier of mice via increasing the expressions of ZO-1 and occludin and enhancing the colonic antioxidative stress property by increasing the levels of T-SOD and GSH-Px and the expressions of NRF2, HO-1, and NQO1 and reducing MDA level and Keap1, p22-phox, and NOX2 expressions. Furthermore, FPH significantly inhibited SLD related to colitis by reducing the abnormal levels of the liver index, ALT, AST, and cytokines including TNFα, LPS, LBP, sCD14, and IL-18 in the livers, as well as decreasing the protein expressions of NLRP3, TNFα, LBP, CD14, TLR4, MyD88, NF-κB, and p-NF-κB, suggesting that FPH alleviated UC-related SLD via suppressing inflammation mediated by inhibiting the TLR4/MyD88/NF-κB pathway. Our study firstly investigates the anticolitis pharmacological efficacy of FPH, suggesting that it can be enlarged to treat colitis and colitis-associated liver diseases in humans.
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Leung KK, Deeb M, Fischer SE, Gulamhusein A. Recurrent Primary Sclerosing Cholangitis: Current Understanding, Management, and Future Directions. Semin Liver Dis 2021; 41:409-420. [PMID: 34182588 DOI: 10.1055/s-0041-1730950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Patients with primary sclerosing cholangitis (PSC) constitute 5 to 15% of patients listed for liver transplantation worldwide. Although post-transplant outcomes are favorable, recurrent PSC (rPSC) occurs in an important subset of patients, with higher prevalence rates reported with increasing time from transplant. Given its association with poor graft outcomes and risk of retransplant, effort has been made to understand rPSC, its pathophysiology, and risk factors. This review covers these facets of rPSC and focuses on implicated risk factors including pretransplant recipient characteristics, inflammatory bowel-disease-related factors, and donor-specific and transplant-specific factors. Confirming a diagnosis of rPSC requires thoughtful consideration of alternative etiologies so as to ensure confidence in diagnosis, management, subsequent risk assessment, and counseling for patients. Unfortunately, no cure exists for rPSC; however, future large-scale efforts are underway to better characterize the natural history of rPSC and its associated risk factors with hopes of identifying potential key targets for novel therapies.
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Affiliation(s)
- Kristel K Leung
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Maya Deeb
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sandra E Fischer
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada
| | - Aliya Gulamhusein
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
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Du W, Han W, Dong J. Long-term oral vancomycin for refractory inflammatory bowel diseases without Clostridium difficile infection: Lessons from primary sclerosing cholangitis. Med Hypotheses 2020; 144:110211. [PMID: 33254520 DOI: 10.1016/j.mehy.2020.110211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/09/2020] [Accepted: 08/20/2020] [Indexed: 02/07/2023]
Abstract
Dysbiosis is a prominent feature of inflammatory bowel diseases (IBD). However, the efficacy of using antibiotics aiming at the aberrant gut microflora for IBD treatment are either unsuccessful or not persistent. In contrast, long-term oral vancomycin has been proved effective in controlling both the bile duct and gut inflammation of primary sclerosing cholangitis (PSC), an autoimmune disease against the intra- and extrahepatic bile ducts that holds a high rate of concomitant IBD and shares many common characteristics with IBD, including similar dysbiosis patterns. Two discrepancies of antibiotic usage might explain the dramatically different responses of the two diseases toward this strategy. First, the vast majority of antibiotic formulas for IBD management consist of broad-spectrum antibiotics mainly targeting gram-negative bacteria with some covering anaerobes and gram-positive ones, while vancomycin used for PSC treatment almost exclusively targets gram-positive bacteria. Several lines of clues suggested that gram-positive microorganisms might be responsible for the chronic inflammation observed in IBD and PSC. Second, improvement of liver test in PSC patients is usually observed after a relatively long period of oral vancomycin treatment (more than 12 weeks) and it takes even longer for gut mucosal healing. Moreover, long-term low dose oral vancomycin is required to prevent PSC recurrence. However, most trials of using antibiotics for IBD management is aiming at inducing remission with short treatment course (most less than 2 weeks) without maintenance. We hypothesize that the host antimicrobial response favors the growth of certain gram-positive intestinal bacteria in genetically predisposed individuals which is responsible for the aberrant immunological reaction towards the gut mucosa. Oral vancomycin induces disease remission by suppressing the pathogenic gram-positive microorganisms, but long course is needed since the gut inflammation is usually severe than that concomitant with PSC. Moreover, long-term maintenance is required to prevent the rebound of the pathogens and flare of the intestinal inflammation.
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Affiliation(s)
- Wei Du
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032 Shaanxi Province, PR China; Grade 2016, School of Basic Medicine, Fourth Military Medical University, Xi'an, 710032 Shaanxi Province, PR China
| | - Weili Han
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032 Shaanxi Province, PR China
| | - Jiaqiang Dong
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032 Shaanxi Province, PR China.
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10
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Akiyama S, Rai V, Rubin DT. Pouchitis in inflammatory bowel disease: a review of diagnosis, prognosis, and treatment. Intest Res 2020; 19:1-11. [PMID: 33138344 PMCID: PMC7873408 DOI: 10.5217/ir.2020.00047] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/18/2020] [Indexed: 12/11/2022] Open
Abstract
Patients with inflammatory bowel disease (IBD) occasionally need a restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) because of medically refractory colitis or dysplasia/cancer. However, pouchitis may develop in up to 70% of patients after this procedure and significantly impair quality of life, more so if the inflammation becomes a chronic condition. About 10% of patients with IBD who develop pouchitis require pouch excision, and several risk factors of the failure have been reported. A phenotype that has features similar to Crohn’s disease may develop in a subset of ulcerative colitis patients following proctocolectomy with IPAA and is the most frequent reason for pouch failure. In this review, we discuss the diagnosis and prognosis of pouchitis, risk factors for pouchitis development, and treatment options for pouchitis, including the newer biological agents.
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Affiliation(s)
- Shintaro Akiyama
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
| | - Victoria Rai
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
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11
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El-Shabrawi MHF, Tarek S, Abou-Zekri M, Meshaal S, Enayet A, Mogahed EA. Hepatobiliary manifestations in children with inflammatory bowel disease: A single-center experience in a low/middle income country. World J Gastrointest Pharmacol Ther 2020; 11:48-58. [PMID: 32844043 PMCID: PMC7416377 DOI: 10.4292/wjgpt.v11.i3.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/28/2020] [Accepted: 07/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There has been a worldwide increase in the reported incidence of inflammatory bowel disease (IBD) in children over the past 2-3 decades. The hepatobiliary (HB) manifestations of IBD have been well-studied in children in industrialized and developed countries but are infrequently reported in low- and middle-income countries (LMIC) such as Egypt.
AIM To determine the prevalence of the HB manifestations in a cohort of Egyptian children with IBD.
METHODS This cross-sectional observational study was carried out over a period of 6 mo (between June 2013 to December 2013) at the Paediatric Hepatology and Gastroenterology Units of Cairo University Children's Hospital, which is the largest paediatric tertiary care centre in the country.
RESULTS The study included 48 patients with confirmed IBD based upon clinical, laboratory, endoscopic and histopathological features, 29 (60.4%) were male. Twenty-four patients (50%) had ulcerative colitis (UC), 11 (22.9%) had Crohn's disease (CD) and 13 (27.1%) had unclassified-IBD (IBD-U), which was formerly known as indeterminate colitis. The mean age of the patients at the time of presentation was 8.14 (± SD 4.02) years and the mean age at the time of study enrolment was 10.16 (± SD 4.19) years. All patients were screened for HB manifestations by physical examination, liver function tests, imaging and liver biopsy when indicated. HB disorders were confirmed in 13 patients (27.1%). Transaminases were elevated in 3 patients (6.3%). Two patients (4.2%) had elevated biliary enzymes (one was diagnosed as primary sclerosing cholangitis (PSC) and the other was diagnosed with PSC/autoimmune hepatitis overlap syndrome and the third patient had hepatitis C virus infection. Ten patients (20.8%) had bright echogenic liver on ultrasound suggesting fatty infiltration as a sequel of malnutrition or medication toxicity.
CONCLUSION The commonest HB disorders in Egyptian children with IBD were abnormal liver function tests, fatty infiltration and PSC. These HB manifestations in paediatric patients in LMIC may be relatively more common than in industrialized countries. Therefore, IBD patients in LMIC should be meticulously screened for liver disease to allow prompt diagnosis and management.
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Affiliation(s)
- Mortada HF El-Shabrawi
- Department of Paediatrics, Kasr Alainy School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Sara Tarek
- Department of Paediatrics, Kasr Alainy School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Maha Abou-Zekri
- Department of Paediatrics, Kasr Alainy School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Safa Meshaal
- Department of Clinical Pathology, Kasr Alainy School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Afaf Enayet
- Department of Paediatrics, Kasr Alainy School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Engy Adel Mogahed
- Department of Paediatrics, Kasr Alainy School of Medicine, Cairo University, Cairo 11562, Egypt
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12
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Yaccob A, Mari A. Practical clinical approach to the evaluation of hepatobiliary disorders in inflammatory bowel disease. Frontline Gastroenterol 2019; 10:309-315. [PMID: 31281626 PMCID: PMC6583566 DOI: 10.1136/flgastro-2018-101037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/06/2018] [Accepted: 09/22/2018] [Indexed: 02/04/2023] Open
Abstract
Hepatobiliary disorders are frequent extraintestinal manifestations in inflammatory bowel disease (IBD) and may appear at any time point during the natural course of the disease. Conceptually, these manifestations can be categorised as: (1) disorders that have an association with IBD; (2) diseases directly and structurally related to intestinal inflammation; (3) diseases related to the adverse effects of IBD treatment; and (4) disorders stemming from the metabolic derangements caused by IBD. The clinical presentations of these disorders range from a mild transient elevation of liver enzymes to liver failure and death. Given this wide differential diagnosis and spectrum of severity, it is understandable that the evaluation of patients with IBD with a hepatobiliary abnormality is often challenging. In this review, we present a concise summary of the common hepatic manifestations seen in patients with IBD and focus on the relevant practical issues encountered by gastroenterologists caring for patients with IBD. A practical clinical approach to the evaluation of liver enzyme abnormalities in patients with IBD is provided based on the predominant enzyme elevation pattern (hepatocellular vs cholestatic), before presenting a working scheme for the prevention of hepatitis B virus (HBV) reactivation in patients with IBD receiving immunosuppressive medications. Finally, we specify several laboratory alterations seen in patients with IBD that can potentially interfere with the interpretation of liver function tests, before defining the specific circumstances when a referral for a hepatological consultation is required for further assessment.
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Affiliation(s)
- Afif Yaccob
- Liver Disease Center, Rambam Healthcare Campus, Haifa, Israel
| | - Amir Mari
- Gastroenterology and Hepatology Institute, Hillel Yaffe Medical Centre, Hadera, Israel
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13
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Nakamoto N, Sasaki N, Aoki R, Miyamoto K, Suda W, Teratani T, Suzuki T, Koda Y, Chu PS, Taniki N, Yamaguchi A, Kanamori M, Kamada N, Hattori M, Ashida H, Sakamoto M, Atarashi K, Narushima S, Yoshimura A, Honda K, Sato T, Kanai T. Gut pathobionts underlie intestinal barrier dysfunction and liver T helper 17 cell immune response in primary sclerosing cholangitis. Nat Microbiol 2019; 4:492-503. [PMID: 30643240 DOI: 10.1038/s41564-018-0333-1] [Citation(s) in RCA: 258] [Impact Index Per Article: 51.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 11/29/2018] [Indexed: 02/07/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic inflammatory liver disease and its frequent complication with ulcerative colitis highlights the pathogenic role of epithelial barrier dysfunction. Intestinal barrier dysfunction has been implicated in the pathogenesis of PSC, yet its underlying mechanism remains unknown. Here, we identify Klebsiella pneumonia in the microbiota of patients with PSC and demonstrate that K. pneumoniae disrupts the epithelial barrier to initiate bacterial translocation and liver inflammatory responses. Gnotobiotic mice inoculated with PSC-derived microbiota exhibited T helper 17 (TH17) cell responses in the liver and increased susceptibility to hepatobiliary injuries. Bacterial culture of mesenteric lymph nodes in these mice isolated K. pneumoniae, Proteus mirabilis and Enterococcus gallinarum, which were prevalently detected in patients with PSC. A bacterial-organoid co-culture system visualized the epithelial-damaging effect of PSC-derived K. pneumoniae that was associated with bacterial translocation and susceptibility to TH17-mediated hepatobiliary injuries. We also show that antibiotic treatment ameliorated the TH17 immune response induced by PSC-derived microbiota. These results highlight the role of pathobionts in intestinal barrier dysfunction and liver inflammation, providing insights into therapeutic strategies for PSC.
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Affiliation(s)
- Nobuhiro Nakamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Tokyo, Japan
| | - Nobuo Sasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Tokyo, Japan.,AMED-CREST, Japan Agency for Medical Research and Development, Tokyo, Japan
| | - Ryo Aoki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Tokyo, Japan.,Institute of Health Science, Ezaki Glico Co., Ltd, Osaka, Japan
| | - Kentaro Miyamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Tokyo, Japan.,Miyarisan Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Wataru Suda
- Department of Microbiology and Immunology, Keio University School of Medicine, Shinanomachi, Tokyo, Japan.,Laboratory of Metagenomics, Department of Computational Biology and Medical Sciences, The University of Tokyo, Chiba, Japan
| | - Toshiaki Teratani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Tokyo, Japan
| | - Takahiro Suzuki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Tokyo, Japan.,Miyarisan Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Yuzo Koda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Tokyo, Japan.,Research Unit/Immunology & Inflammation, Sohyaku Innovative Research Division, Mitsubishi Tanabe Pharma Corporation, Kanagawa, Japan
| | - Po-Sung Chu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Tokyo, Japan
| | - Nobuhito Taniki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Tokyo, Japan
| | - Akihiro Yamaguchi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Tokyo, Japan
| | - Mitsuhiro Kanamori
- Department of Microbiology and Immunology, Keio University School of Medicine, Shinanomachi, Tokyo, Japan
| | - Nobuhiko Kamada
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Masahira Hattori
- Laboratory of Metagenomics, Department of Computational Biology and Medical Sciences, The University of Tokyo, Chiba, Japan.,Cooperative Major in Advanced Health Science, Graduate School of Advanced Science and Engineering, Faculty of Science and Engineering, Waseda University, Tokyo, Japan
| | - Hiroshi Ashida
- Department of Bacterial Infection and Host Response, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Michiie Sakamoto
- Department of Pathology, Keio University School of Medicine, Shinanomachi, Tokyo, Japan
| | - Koji Atarashi
- Department of Microbiology and Immunology, Keio University School of Medicine, Shinanomachi, Tokyo, Japan.,RIKEN Center for Integrative Medical Sciences, Laboratory for Gut Homeostasis, Kanagawa, Japan
| | - Seiko Narushima
- Department of Microbiology and Immunology, Keio University School of Medicine, Shinanomachi, Tokyo, Japan.,RIKEN Center for Integrative Medical Sciences, Laboratory for Gut Homeostasis, Kanagawa, Japan
| | - Akihiko Yoshimura
- Department of Microbiology and Immunology, Keio University School of Medicine, Shinanomachi, Tokyo, Japan
| | - Kenya Honda
- Department of Microbiology and Immunology, Keio University School of Medicine, Shinanomachi, Tokyo, Japan.,RIKEN Center for Integrative Medical Sciences, Laboratory for Gut Homeostasis, Kanagawa, Japan
| | - Toshiro Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Tokyo, Japan.
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Tokyo, Japan. .,AMED-CREST, Japan Agency for Medical Research and Development, Tokyo, Japan.
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14
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Khan N, Trivedi C, Shah Y, Cole E, Lewis J, Yang YX. The Natural History of Newly Diagnosed Ulcerative Colitis in Patients with Concomitant Primary Sclerosing Cholangitis. Inflamm Bowel Dis 2018; 24:2062-2067. [PMID: 29697792 DOI: 10.1093/ibd/izy106] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Primary sclerosing cholangitis (PSC) is commonly associated with ulcerative colitis (UC). Our aim was to compare the course of disease in patients with UC-PSC and UC alone in a nationwide cohort. METHODS We conducted a retrospective cohort study among nation-wide Veterans Affairs (VA) patients newly diagnosed with UC to determine the association between PSC status and clinical outcomes related to UC disease course. This study was divided into 2 groups of patients: (1) The incident UC-PSC group and (2) the incident UC-alone group. Follow-up began at the time of index colonoscopy that diagnosed UC and ended at the first occurrence of the respective outcome for the regression analysis of the following censoring events: (1) colectomy, (2) death, (3) end of follow-up, and (4 lost to follow-up. RESULTS The analysis included 836 UC patients without PSC and 74 UC-PSC patients. In univariate comparisons, PSC patients were more likely to have more extensive UC than those without PSC. In a multivariable Cox regression analysis adjusting for sex, age at UC diagnosis, race, severity of UC, and extent of UC, PSC status was not associated with the risk of colectomy for UC, increased risk of receiving ≥ 2 courses of steroids for UC, or with the risk of receiving immunomodulators for UC. CONCLUSION UC-PSC patients do not have a more benign disease course than UC patients without PSC. UC-PSC patients may have a modestly increased risk for multiple courses of steroids, which may be mediated by more extensive colonic involvement.
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Affiliation(s)
- Nabeel Khan
- Section of Gastroenterology, Corporal Michael J. Crescenz Medical Center, Pennsylvania, USA.,Section of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Guardian Drive, PA, USA
| | - Chinmay Trivedi
- Section of Gastroenterology, Corporal Michael J. Crescenz Medical Center, Pennsylvania, USA
| | - Yash Shah
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, James J. Peters VA Medical Center, NY, USA
| | - Elisabeth Cole
- Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, PA, USA
| | - James Lewis
- Section of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Yu-Xiao Yang
- Section of Gastroenterology, Corporal Michael J. Crescenz Medical Center, Pennsylvania, USA.,Section of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Guardian Drive, PA, USA
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15
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Tripathi A, Debelius J, Brenner DA, Karin M, Loomba R, Schnabl B, Knight R. The gut-liver axis and the intersection with the microbiome. Nat Rev Gastroenterol Hepatol 2018; 15:397-411. [PMID: 29748586 PMCID: PMC6319369 DOI: 10.1038/s41575-018-0011-z] [Citation(s) in RCA: 797] [Impact Index Per Article: 132.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In the past decade, an exciting realization has been that diverse liver diseases - ranging from nonalcoholic steatohepatitis, alcoholic steatohepatitis and cirrhosis to hepatocellular carcinoma - fall along a spectrum. Work on the biology of the gut-liver axis has assisted in understanding the basic biology of both alcoholic fatty liver disease and nonalcoholic fatty liver disease (NAFLD). Of immense importance is the advancement in understanding the role of the microbiome, driven by high-throughput DNA sequencing and improved computational techniques that enable the complexity of the microbiome to be interrogated, together with improved experimental designs. Here, we review gut-liver communications in liver disease, exploring the molecular, genetic and microbiome relationships and discussing prospects for exploiting the microbiome to determine liver disease stage and to predict the effects of pharmaceutical, dietary and other interventions at a population and individual level. Although much work remains to be done in understanding the relationship between the microbiome and liver disease, rapid progress towards clinical applications is being made, especially in study designs that complement human intervention studies with mechanistic work in mice that have been humanized in multiple respects, including the genetic, immunological and microbiome characteristics of individual patients. These 'avatar mice' could be especially useful for guiding new microbiome-based or microbiome-informed therapies.
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Affiliation(s)
- Anupriya Tripathi
- Division of Biological Sciences, University of California, San Diego, La Jolla, CA, USA
- Department of Pediatrics, University of California, San Diego, CA, USA
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA, USA
| | - Justine Debelius
- Department of Pediatrics, University of California, San Diego, CA, USA
| | - David A Brenner
- NAFLD Research Center, Division of Gastroenterology, Department of Medicine, University of California, San Diego, CA, USA
| | - Michael Karin
- Department of Pediatrics, University of California, San Diego, CA, USA
- Department of Computer Science and Engineering, University of California, San Diego, CA, USA
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology, Department of Medicine, University of California, San Diego, CA, USA
- Center for Microbiome Innovation, University of California, San Diego, CA, USA
| | - Bernd Schnabl
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA
- Department of Medicine, VA San Diego Healthcare System, San Diego, CA, USA
- Center for Microbiome Innovation, University of California, San Diego, CA, USA
| | - Rob Knight
- Department of Pediatrics, University of California, San Diego, CA, USA.
- Department of Computer Science and Engineering, University of California, San Diego, CA, USA.
- Center for Microbiome Innovation, University of California, San Diego, CA, USA.
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16
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Principi M, Iannone A, Losurdo G, Mangia M, Shahini E, Albano F, Rizzi SF, La Fortezza RF, Lovero R, Contaldo A, Barone M, Leandro G, Ierardi E, Di Leo A. Nonalcoholic Fatty Liver Disease in Inflammatory Bowel Disease: Prevalence and Risk Factors. Inflamm Bowel Dis 2018; 24:1589-1596. [PMID: 29688336 DOI: 10.1093/ibd/izy051] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is common in inflammatory bowel diseases (IBD). Herein, NAFLD prevalence and risk factors in a large IBD cohort were evaluated and compared to that of a non-IBD sample. METHODS Crohn's disease/ulcerative colitis outpatients referred to IBD service of our Gastroenterology Unit were enrolled. Subjects affected by functional and motor gastrointestinal disorders, in whom IBD was ruled out, referred to general outpatient service in the same area, were considered as nonIBD group. Exclusion criteria were based on previous diagnosis of nonNAFLD chronic liver diseases and secondary causes of fat liver overload. Characteristics of IBD and liver status were collected. Risk factors for metabolic syndrome were analyzed. Ultrasonographic presence and degree of steatosis were assessed. Data were examined by univariate and multivariate analyses. RESULTS For this study 465 IBD and 189 non-IBD subjects were consecutively enrolled. NAFLD was found in 28.0% and 20.1% in IBD and non-IBD subjects, respectively (P = 0.04). IBD patients with NAFLD were younger than non-IBD ones. There was no significant difference in steatosis grade and association between NAFLD and IBD behavior, extension, activity, and drugs. In the IBD group, multivariate analysis demonstrated that NAFLD was independently associated to metabolic syndrome (OR=2.24, 95%CI 1.77-28.81), diabetes (OR=1.71, 95%CI 1.43-12.25), fasting blood glucose (OR=1.36, 95%CI 1.13-1.68), and abdominal circumference (OR=1.68, 95%CI 1.15-14.52). CONCLUSIONS NAFLD is more common and occurs at a younger age in IBD than in nonIBD subjects. However, further investigation is required to ascertain possible NAFLD pathogenic IBD-related factors other than conventional/metabolic ones. 10.1093/ibd/izy051_video1izy051.video15774874877001.
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Affiliation(s)
- Mariabeatrice Principi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, University of Bari, Italy
| | - Andrea Iannone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, University of Bari, Italy
| | - Giuseppe Losurdo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, University of Bari, Italy
| | - Michela Mangia
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, University of Bari, Italy
| | - Endrit Shahini
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, University of Bari, Italy
| | - Francesca Albano
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, University of Bari, Italy
| | - Salvatore Fabio Rizzi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, University of Bari, Italy
| | - Rosa Federica La Fortezza
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, University of Bari, Italy
| | - Rosa Lovero
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, University of Bari, Italy
| | - Antonella Contaldo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, University of Bari, Italy
| | - Michele Barone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, University of Bari, Italy
| | - Gioacchino Leandro
- National Institute of Gastroenterology, "S De Bellis" Research Hospital, Castellana Grotte, Italy
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, University of Bari, Italy
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, University of Bari, Italy
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17
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The gastroenterologist's guide to management of the post-liver transplant patient. Am J Gastroenterol 2018; 113:819-828. [PMID: 29748558 DOI: 10.1038/s41395-018-0049-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/11/2018] [Indexed: 12/11/2022]
Abstract
The management of the post-liver transplant patient is complex and involves a large interdisciplinary team. After referral to a transplant center, evaluation and listing, and eventual transplantation, the patient is cared for closely by the transplant center. Once deemed ready for discharge, the patient returns to the primary care provider for ongoing management of the various issues that increase in incidence post transplant such as osteoporosis, cardiovascular, and renal diseases, as well as metabolic syndrome. The role of the gastroenterologist is not well defined, but certainly, he or she may be called upon for the initial evaluation and ongoing management of gastrointestinal as well as hepatobiliary issues. This includes but is not limited to the investigation of abnormal liver tests, non-specific gastrointestinal complaints such as nausea, vomiting, or diarrhea, biliary complications, and even recurrent hepatic disease. Having familiarity with post-transplant immunosuppressive agents, drug interactions, and potential infectious and malignancy-related complications of transplant is essential, as the primary gastroenterologist may be expected in some situations to field the initial work-up, if patient access to the transplant center is limited. The aim of this review is to summarize the gastroenterologist's role in the management of the post-liver transplant patient.
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18
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Mouchli MA, Singh S, Boardman L, Bruining DH, Lightner AL, Rosen CB, Heimbach JK, Hasan B, Poterucha JJ, Watt KD, Kane SV, Raffals LE, Loftus EV. Natural History of Established and De Novo Inflammatory Bowel Disease After Liver Transplantation for Primary Sclerosing Cholangitis. Inflamm Bowel Dis 2018; 24. [PMID: 29522202 PMCID: PMC6085995 DOI: 10.1093/ibd/izx096] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The course of inflammatory bowel disease (IBD) after liver transplantation (LT) for primary sclerosing cholangitis (PSC) is poorly understood. We describe the natural history of established IBD after LT (including risk of disease progression, colectomy, and neoplasia) and de novo IBD. METHODS In a retrospective cohort, we identified all patients with PSC who underwent LT for advanced PSC at Mayo Clinic, Rochester, Minnesota. Risk factors were identified using multivariate Cox proportional hazard analysis. RESULTS Three hundred seventy-three patients were identified (mean age, 47.5 ± 11.7 years; 64.9% male). Over a median (range) of 10 (5.5-17.1) years, 151 patients with PSC-IBD with an intact colon at the time of LT were studied. Post-LT, despite transplant-related immunosuppression, 56/151 (37.1%) required escalation of therapy, whereas 87 had a stable course (57.6%) and 8 patients (5.3%) improved. The 1-, 5-, and 10-year risks of progression of IBD were 4.0%, 18.5%, and 25.5%, respectively. On multivariate analysis, tacrolimus-based immunosuppression post-LT were associated with unfavorable course, and azathioprine use after LT was associated with improved course post-LT. Of 84 patients with no evidence of IBD at the time of LT, 22 (26.2%) developed de novo IBD post-LT. The 1-, 5-, and 10-year cumulative incidences of de novo IBD were 5.5%, 20.0%, and 25.4%, respectively. On univariate analysis, mycophenolate mofetil use after LT was associated with increased risk of de novo IBD, but azathioprine use after LT seemed to be protective. CONCLUSIONS The 10-year cumulative probability of IBD flare requiring escalation of therapy after LT for PSC was 25.5%, despite immunosuppression for LT. The 10-year cumulative risk of de novo IBD after LT for PSC was 25.4%. Transplant-related immunosuppression may modify the risk of de novo IBD, with an increased risk with mycophenolate and a decreased risk with azathioprine. 10.1093/ibd/izx096_video1izx096.video15746673864001.
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Affiliation(s)
- Mohamad A Mouchli
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota,Division of Gastroenterology and Hepatology, Carilion Clinic, Roanoke, Virginia
| | - Siddharth Singh
- Division of Gastroenterology, Department of Internal Medicine, UCSD, La Jolla, California
| | - Lisa Boardman
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Charles B Rosen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Julie K Heimbach
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Bashar Hasan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - John J Poterucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota,Address correspondence to: Edward V. Loftus, Jr., MD, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905 ()
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Protective roles and mechanisms of Dendrobium officinal polysaccharides on secondary liver injury in acute colitis. Int J Biol Macromol 2018; 107:2201-2210. [DOI: 10.1016/j.ijbiomac.2017.10.085] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 10/03/2017] [Accepted: 10/14/2017] [Indexed: 12/26/2022]
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Westerouen van Meeteren MJ, Hayee B, Inderson A, van der Meulen AE, Altwegg R, van Hoek B, Pageaux GP, Stijnen T, Stein D, Maljaars PWJ. Safety of Anti-TNF Treatment in Liver Transplant Recipients: A Systematic Review and Meta-analysis. J Crohns Colitis 2017; 11:1146-1151. [PMID: 28482085 DOI: 10.1093/ecco-jcc/jjx057] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 04/21/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIM Little is known about the risk of serious infection when combining anti-tumour necrosis factor [TNF] therapy for refractory inflammatory bowel disease [IBD] with immunosuppression after liver transplantation [LT]. Our aim was to investigate the infection risk in this patient group by systematic review and meta-analysis of the available data. METHODS A search was conducted for full papers and conference proceedings through September 2015, regarding liver transplant recipients and anti-TNF therapy. All studies were appraised using the adapted Newcastle-Ottawa Scale [NOS]. Two reviewers independently extracted patient data [age, duration of follow-up, number of all infections, number of serious infections, time since transplant]. As an additional control population, primary sclerosing cholangitis [PSC]-IBD patients from the Leiden University Medical Center [LUMC] LT cohort were used. Poisson regression was used to compare serious infections (according to International Conference on Harmonisation [ICH] definition) per patien-year follow-up between the anti-TNF and control groups. RESULTS In all 465 articles and abstracts were identified, of which eight were included. These contained 53 post-LT patients on anti-TNF therapy and 23 post-LT patients not exposed to anti-TNF therapy. From the LUMC LT-cohort, 41 PSC patients with PSC-IBD not exposed to anti-TNF therapy were included as control population. The infection rate for TNF-exposed patients was 0.168 serious infections per patient year, compared with 0.149 in the control patients (rate ratio 1.12 [95% confidence interval: 0.233-5.404, P = 0.886]. When correcting for time since transplant, the infection rate was 0.194 in the TNF-exposed vs 0.115 in the non-exposed [p = 0.219]. CONCLUSIONS No significant increase in the rate of serious infection was observed in LT recipients with PSC-IBD during exposure to anti-TNF therapy.
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Affiliation(s)
| | - B Hayee
- King's College Hospital, Department of Gastroenterology, London, UK
| | - A Inderson
- Leiden University Medical Centre, Department of Gastroenterology-Hepatology, Leiden, The Netherlands
| | - A E van der Meulen
- Leiden University Medical Centre, Department of Gastroenterology-Hepatology, Leiden, The Netherlands
| | - R Altwegg
- University Hospital of St Eloi, Department of Hepatology and Gastroenterology, Montpellier, France
| | - B van Hoek
- Leiden University Medical Centre, Department of Gastroenterology-Hepatology, Leiden, The Netherlands
| | - G P Pageaux
- University Hospital of St Eloi, Department of Hepatology and Gastroenterology, Montpellier, France
| | - T Stijnen
- Leiden University Medical Centre, Department of Medical Statistics, Leiden, The Netherlands
| | - D Stein
- Medical College of Wisconsin, Department of Gastroenterology and Hepatology, Milwaukee, WI, USA
| | - P W J Maljaars
- Leiden University Medical Centre, Department of Gastroenterology-Hepatology, Leiden, The Netherlands
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21
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Arndtz K, Corrigan M, Rowe A, Kirkham A, Barton D, Fox RP, Llewellyn L, Athwal A, Wilkhu M, Chen YY, Weston C, Desai A, Adams DH, Hirschfield GM. Investigating the safety and activity of the use of BTT1023 (Timolumab), in the treatment of patients with primary sclerosing cholangitis (BUTEO): A single-arm, two-stage, open-label, multi-centre, phase II clinical trial protocol. BMJ Open 2017; 7:e015081. [PMID: 28674140 PMCID: PMC5734279 DOI: 10.1136/bmjopen-2016-015081] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 03/29/2017] [Accepted: 05/17/2017] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Primary sclerosing cholangitis (PSC) is a progressive inflammatory liver disease characterised by relentless liver fibrosis and a high unmet need for new therapies. Preventing fibrosis represents an important area of interest in the development of vital new drugs. Vascular adhesion protein-1 (VAP-1) drives inflammation in liver disease, and provision of an antibody against VAP-1 blunts fibrosis in murine models of liver injury. METHODS AND ANALYSIS BUTEO is a single-arm, two-stage, open-label, multi-centre, phase II clinical trial. Up to 59 patients will receive treatment with anti-VAP monoclonal antibody, BTT1023, over a 78-day treatment period. Adults with PSC and a serum alkaline phosphatase (ALP) of at least 1.5 times the upper limit of normal will be included. Our primary outcome measure is a reduction in ALP by >25% from baseline to Day 99. Secondary outcome measures include safety and tolerability, changes pre therapy/post therapy in circulating serum VAP-1 as well as imaging findings. The first patient participant was recruited on 08 September 2015. ETHICS AND DISSEMINATION This protocol has been approved by the Research Ethics Committee (REC, reference 14/EM/1272). The first REC approval date was 06 January 2015 with three subsequent approved amendments. This article refers to protocol V3.0, dated 16 March 2016. Results will be disseminated via peer-reviewed publication and presentation at international conferences. TRIAL REGISTRATION The trial is registered with the European Medicines agency (EudraCT: 2014-002393-37), the National Institute for Health Research (Portfolio ID: 18051) and ISRCTN: 11233255. The clinicaltrials.gov identifier is NCT02239211. Pre-results.
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Affiliation(s)
- Katherine Arndtz
- Centre for Rare Diseases, Institute of Translational Medicine, Birmingham Health Partners, University Hospitals Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Margaret Corrigan
- Centre for Rare Diseases, Institute of Translational Medicine, Birmingham Health Partners, University Hospitals Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Anna Rowe
- NIHR Birmingham Biomedical Research Centre, Clinical Trials Group (D3B Team), CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Amanda Kirkham
- Department of Statistics, CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Darren Barton
- NIHR Birmingham Biomedical Research Centre, Clinical Trials Group (D3B Team), CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Richard P Fox
- Department of Statistics, CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Laura Llewellyn
- Early Drug Development Team, CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Amrita Athwal
- NIHR Birmingham Biomedical Research Centre, Clinical Trials Group (D3B Team), CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Manpreet Wilkhu
- NIHR Birmingham Biomedical Research Centre, Clinical Trials Group (D3B Team), CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Yung-Yi Chen
- Centre for Rare Diseases, Institute of Translational Medicine, Birmingham Health Partners, University Hospitals Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Chris Weston
- Centre for Rare Diseases, Institute of Translational Medicine, Birmingham Health Partners, University Hospitals Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Amisha Desai
- Pharmacy, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - David H Adams
- Centre for Rare Diseases, Institute of Translational Medicine, Birmingham Health Partners, University Hospitals Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Gideon M Hirschfield
- Centre for Rare Diseases, Institute of Translational Medicine, Birmingham Health Partners, University Hospitals Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, UK
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Restellini S, Chazouillères O, Frossard JL. Hepatic manifestations of inflammatory bowel diseases. Liver Int 2017; 37:475-489. [PMID: 27712010 DOI: 10.1111/liv.13265] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 09/27/2016] [Indexed: 12/18/2022]
Abstract
Inflammatory bowel diseases are associated with various hepatobiliary disorders, reported both in Crohn's disease and ulcerative colitis. They may occur at any moment in the natural course of the disease. The prevalence of liver dysfunction rises from 3% to 50% accordingly to definitions used in different studies. Fatty liver is considered as the most common hepatobiliary complication in inflammatory bowel diseases while primary sclerosing cholangitis is the most specific one. Less frequently, inflammatory bowel diseases-associated hepatobiliary disorders include: autoimmune hepatitis/ primary sclerosing cholangitis overlap syndrome, IgG4-associated cholangiopathy, primary biliary cholangitis, hepatic amyloidosis, granulomatous hepatitis, cholelithiasis, portal vein thrombosis and liver abscess. The spectrum of these manifestations varies according to the type of inflammatory bowel diseases. Treatments of inflammatory bowel diseases may cause liver toxicity, although incidence of serious complications remains low. However, early diagnosis of drug-induced liver injury is of major importance as it affects future clinical management. When facing abnormal liver tests, clinicians should undertake a full diagnostic work-up in order to determine whether the hepatic abnormalities are related to the inflammatory bowel diseases or not. Management of hepatic manifestations in inflammatory bowel diseases usually involves both hepatologists and gastroenterologists because of the complexity of some situations.
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Affiliation(s)
- Sophie Restellini
- Service de Gastroentérologie et Hépatologie, Hôpitaux Universitaires de Genève, Genève, Suisse
| | - Olivier Chazouillères
- Division d'Hépatologie, Centre de Référence des Maladies Inflammatoires des Voies Biliaires, et Université de Sorbonne, UPMC Univ Paris 06, UMR_S 938, CDR Saint-Antoine, AP-HP, Hôpital Saint-Antoine, Paris, France
| | - Jean-Louis Frossard
- Service de Gastroentérologie et Hépatologie, Hôpitaux Universitaires de Genève, Genève, Suisse
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Barendregt J, de Jong M, Haans JJ, van Hoek B, Hardwick J, Veenendaal R, van der Meulen A, Srivastava N, Stuyt R, Maljaars J. Liver test abnormalities predict complicated disease behaviour in patients with newly diagnosed Crohn's disease. Int J Colorectal Dis 2017; 32:459-467. [PMID: 27900523 PMCID: PMC5355514 DOI: 10.1007/s00384-016-2706-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUNDS In coeliac disease, the prevalence of liver test abnormalities (LTAs) is higher in patients with more severe mucosal inflammation. In Crohn's disease, prognosis is related to the severity of mucosal inflammation. AIM The aim of this study was to investigate whether the presence of LTA predicts the occurrence of complicated disease behaviour in newly diagnosed Crohn's disease. METHODS A retrospective cohort study was performed in patients newly diagnosed with Crohn's disease between 2002 and 2011. The complicated disease was defined as the occurrence of stricturing and/or perforating disease. LTAs were defined as a value of any of alkaline phosphatase (AP), gamma-glutamyl transpeptidase (GGT), aspartate aminotransferase (AST), or alanine aminotransferase (ALT) over the upper limit of normal. RESULTS Three hundred eighty-three patients were included, of whom 34.1% had LTA. LTAs were mostly mild (less than two times the upper limit of normal). During the 5-year follow-up, 33.1% of patients in the group with LTA developed complicated disease behaviour compared to 14.6% in patients without LTA (p < 0.001). The presence of LTA was identified as a risk factor for complicated disease behaviour (HR 2.6, 95% confidence interval (CI) 1.5-4.2, p < 0.0001). CONCLUSIONS In newly diagnosed Crohn's disease, the presence of LTA was an independent risk factor for the development of complicated disease behaviour.
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Affiliation(s)
- Jessika Barendregt
- 0000000089452978grid.10419.3dDepartment of Gastroenterology-Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Myrthe de Jong
- 0000000089452978grid.10419.3dDepartment of Gastroenterology-Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jeoffrey J. Haans
- grid.412966.eDepartment of Gastroenterology-Hepatology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bart van Hoek
- 0000000089452978grid.10419.3dDepartment of Gastroenterology-Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - James Hardwick
- 0000000089452978grid.10419.3dDepartment of Gastroenterology-Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Roeland Veenendaal
- 0000000089452978grid.10419.3dDepartment of Gastroenterology-Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Andrea van der Meulen
- 0000000089452978grid.10419.3dDepartment of Gastroenterology-Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Nidhi Srivastava
- Department of Gastroenterology-Hepatology, Haaglanden Medical Centre, The Hague, The Netherlands
| | - Rogier Stuyt
- 0000 0004 0568 6689grid.413591.bDepartment of Gastroenterology-Hepatology, Haga Hospital, The Hague, The Netherlands
| | - Jeroen Maljaars
- 0000000089452978grid.10419.3dDepartment of Gastroenterology-Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
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Mattner J. Impact of Microbes on the Pathogenesis of Primary Biliary Cirrhosis (PBC) and Primary Sclerosing Cholangitis (PSC). Int J Mol Sci 2016; 17:ijms17111864. [PMID: 27834858 PMCID: PMC5133864 DOI: 10.3390/ijms17111864] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/02/2016] [Accepted: 11/04/2016] [Indexed: 02/07/2023] Open
Abstract
Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) represent the major clinical entities of chronic cholestatic liver diseases. Both disorders are characterized by portal inflammation and slowly progress to obliterative fibrosis and eventually liver cirrhosis. Although immune-pathogenic mechanisms have been implicated in the pathogenesis of PBC and PSC, neither disorder is considered to be a classical autoimmune disease, as PSC and PBC patients do not respond to immune-suppressants. Furthermore, the decreased bile flow resulting from the immune-mediated tissue assault and the subsequent accumulation of toxic bile products in PBC and PSC not only perpetuates biliary epithelial damage, but also alters the composition of the intestinal and biliary microbiota and its mutual interactions with the host. Consistent with the close association of PSC and inflammatory bowel disease (IBD), the polyclonal hyper IgM response in PBC and (auto-)antibodies which cross-react to microbial antigens in both diseases, an expansion of individual microbes leads to shifts in the composition of the intestinal or biliary microbiota and a subsequent altered integrity of epithelial layers, promoting microbial translocation. These changes have been implicated in the pathogenesis of both devastating disorders. Thus, we will discuss here these recent findings in the context of novel and alternative therapeutic options.
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MESH Headings
- Anti-Bacterial Agents/therapeutic use
- Antibodies, Bacterial/biosynthesis
- Bacterial Translocation
- Bile/drug effects
- Bile/microbiology
- Cholangiopancreatography, Endoscopic Retrograde
- Cholangitis, Sclerosing/diagnostic imaging
- Cholangitis, Sclerosing/drug therapy
- Cholangitis, Sclerosing/immunology
- Cholangitis, Sclerosing/microbiology
- Gastrointestinal Microbiome/drug effects
- Host-Pathogen Interactions
- Humans
- Immunoglobulin M/biosynthesis
- Liver Cirrhosis, Biliary/diagnostic imaging
- Liver Cirrhosis, Biliary/drug therapy
- Liver Cirrhosis, Biliary/immunology
- Liver Cirrhosis, Biliary/microbiology
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Affiliation(s)
- Jochen Mattner
- Mikrobiologisches Institut-Klinische Mikrobiologie, Immunologie und Hygiene, Universitätsklinikum Erlangen and Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg, Wasserturmstr. 3/5, D-91054 Erlangen, Germany.
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Clinical Features and Risk Factors of Autoimmune Liver Involvement in Pediatric Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2016; 63:259-64. [PMID: 26756875 DOI: 10.1097/mpg.0000000000001078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Autoimmune liver disease is reported in up to 7.8% of children with inflammatory bowel disease. A distinct inflammatory bowel disease phenotype has been suggested in adults and in small pediatric cohorts. The aim of the study was to evaluate the features of inflammatory bowel disease associated with autoimmune liver diseases and to analyze the characteristics of the liver disease. METHODS Information on patients was obtained from the Italian Pediatric Inflammatory Bowel Disease Registry. Data of patients with and without autoimmune liver disease were compared. RESULTS Autoimmune liver disease was detected in 6.8% of the 677 patients enrolled and was significantly associated with the diagnosis of ulcerative colitis (83%), with pancolonic involvement (84%), and with perinuclear antineutrophil cytoplasmic antibody positivity (41%) (all Ps < 0.05). Autoimmune liver disease was defined as sclerosing cholangitis in 61% of the patients and as an overlap syndrome in 33%. Concomitant intra- and extrahepatic biliary involvement was reported in 61% of cases, whereas exclusive extrahepatic lesions were reported in 21%. Hepatobiliary complications were observed in 9% of the patients during follow-up. CONCLUSIONS Autoimmune liver disease, especially sclerosing cholangitis, was significantly more common in patients with extensive ulcerative colitis. Although complications are relatively rare in the pediatric age, monitoring is recommended.
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Navaneethan U, Rai T, Venkatesh PG, Kiran RP. Primary sclerosing cholangitis and the risk of colon neoplasia in patients with Crohn's colitis. Gastroenterol Rep (Oxf) 2015; 4:226-31. [PMID: 25725040 PMCID: PMC4976675 DOI: 10.1093/gastro/gov007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 01/06/2015] [Indexed: 01/20/2023] Open
Abstract
Background and aim: Crohn’s colitis (CC) is associated with primary sclerosing cholangitis (PSC). However the risk of colon cancer or dysplasia in CC and PSC is unclear. Our aim was to study the risk of colon neoplasia in CC in patients with and without PSC. Methods: This is a nested, case-control cohort study of all patients diagnosed with concurrent CC and PSC, seen at the Cleveland Clinic between 1985 and 2012. Forty-three patients with both CC and PSC were compared with a random sample of 159 CC controls without PSC during the same period. Results: Seven (16.3%) of 43 CC patients with PSC developed colon cancer or dysplasia, compared with 22 (13.8%) of 159 controls (P = 0.98). Of seven colon neoplasia cases in the PSC group, 100% occurred proximal to the splenic flexure, compared with 50% (11/22) cases of colon neoplasia in controls occurring in the proximal colon (P = 0.001). Based on Cox regression analysis, male gender independently increased the risk of neoplasia [hazard ratio (HR) = 2.68; 95% confidence interval (CI) 1.30–5.54; P = 0.008], as did age at CC diagnosis (HR = 1.29; 95% CI 1.14–1.47; P < 0.001), while the use of azathioprine/6-mercaptopurine was protective (HR = 0.30; 95% CI 0.13–0.70; P = 0.005). The presence of PSC did not increase the risk for colon neoplasia (HR = 0.45; 95% CI 0.18–1.13; P = 0.09). Conclusions: CC patients with PSC appear not to be at increased risk of developing colon neoplasia. Among patients in our cohort with colon neoplasia and concurrent PSC, the neoplasia occurred in the proximal colon in all cases.
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Affiliation(s)
- Udayakumar Navaneethan
- Department of Gastroenterology, Digestive disease Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Tarun Rai
- Department of Gastroenterology, Digestive disease Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Preethi Gk Venkatesh
- Department of Gastroenterology, Digestive disease Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Ravi P Kiran
- Department of Colorectal Surgery, Digestive disease Institute, The Cleveland Clinic, Cleveland, OH, USA
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Ma HD, Wang YH, Chang C, Gershwin ME, Lian ZX. The intestinal microbiota and microenvironment in liver. Autoimmun Rev 2014; 14:183-91. [PMID: 25315744 DOI: 10.1016/j.autrev.2014.10.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 10/05/2014] [Indexed: 12/12/2022]
Abstract
The intestinal microbiome plays a significant role in the development of autoimmune diseases, in particular, inflammatory bowel diseases. But the interplay between the intestinal tract and the liver may explain the increased association with autoimmune liver diseases and inflammatory bowel diseases. The gut-liver axis involves multiple inflammatory cell types and cytokines, chemokines and other molecules which lead to the destruction of normal liver architecture. Triggers for the initiation of these events are unclear, but appear to include multiple environmental factors, including pathogenic or even commensal microbial agents. The variation in the gut microbiome has been cited as a major factor in the pathogenesis of autoimmune liver disease and even other autoimmune diseases. The unique positioning of the liver at the juncture of the peripheral circulation and the portal circulation augments the interaction between naïve T cells and other hepatic cells and leads to the disruption in the development of tolerance to commensal bacteria and other environmental agents. Finally, the innate immune system and in particular toll-like receptors play a significant role in the pathogenesis of autoimmune liver disease.
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Affiliation(s)
- Hong-Di Ma
- Liver Immunology Laboratory, Institute of Immunology and The CAS Key Laboratory of Innate Immunity and Chronic Disease, School of Life Sciences and Medical Center, University of Science and Technology of China, Hefei, Anhui 230027, China.
| | - Yin-Hu Wang
- Liver Immunology Laboratory, Institute of Immunology and The CAS Key Laboratory of Innate Immunity and Chronic Disease, School of Life Sciences and Medical Center, University of Science and Technology of China, Hefei, Anhui 230027, China.
| | - Christopher Chang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, CA 95616, USA.
| | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, CA 95616, USA.
| | - Zhe-Xiong Lian
- Liver Immunology Laboratory, Institute of Immunology and The CAS Key Laboratory of Innate Immunity and Chronic Disease, School of Life Sciences and Medical Center, University of Science and Technology of China, Hefei, Anhui 230027, China; Innovation Center for Cell Biology, Hefei National Laboratory for Physical Sciences at Microscale, Hefei, Anhui 230027, China.
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Nguyen DL, Bechtold ML, Jamal MM. National trends and inpatient outcomes of inflammatory bowel disease patients with concomitant chronic liver disease. Scand J Gastroenterol 2014; 49:1091-5. [PMID: 24895841 DOI: 10.3109/00365521.2014.921326] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is little information on the frequency of chronic liver disease among hospitalized patients with inflammatory bowel disease (IBD). In this study, we seek to define the common etiologies contributing to chronic liver disease among IBD patients and to identify potential risk factors predictive of increased mortality in this population. METHODS We analyzed the Nationwide Inpatient Sample from 1988 to 2006 to determine the frequency of chronic liver disease among patients with IBD and to determine their in-hospital outcomes. RESULTS From 1988 to 2006, the age-adjusted rate of chronic liver disease among hospitalized patients with IBD has increased from 4.35 per 100,000 persons in 1988-2001 to 7.45 per 100,000 persons in 2004-2006. The most common etiologies contributing to chronic liver disease among IBD patients were: primary sclerosing cholangitis, unspecified chronic hepatitis, chronic hepatitis C, and nonalcoholic fatty liver disease. Compared to IBD patients without liver disease, there was more than a twofold higher rate of inpatient morality among IBD patients with concomitant liver disease (2.7% vs. 1.3%, p < 0.01). The multivariate analysis showed that factors predictive of inpatient mortality include age >50, spontaneous bacterial peritonitis, ascites, hepatic encephalopathy, presence of cirrhosis, malnutrition, Clostridium difficile colitis, and hospital-acquired pneumonia. CONCLUSION There is a higher rate of inpatient mortality among patients with concomitant IBD and chronic liver disease compared to IBD alone. Early recognition and management of complications related to portal hypertension among patients with IBD and chronic liver disease is particularly important in order to reduce inpatient mortality and morbidity.
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Affiliation(s)
- Douglas L Nguyen
- Division of Gastroenterology and Hepatology, University of California-Irvine , Orange, CA , USA
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Abstract
Hepatic involvement is often encountered in gastrointestinal (GI) diseases, in part because of the close anatomic and physiologic relations between the liver and GI tract. Drainage of the mesenteric blood supply to the portal vein permits absorbed and/or translocated nutrients, toxins, bacterial elements, cytokines, and immunocytes to gain hepatic access. Liver problems in digestive disorders may range from nonspecific hepatocellular enzyme elevations to significant pathologic processes that may progress to end-stage liver disease. Hepatobiliary manifestations of primary GI diseases in childhood and adolescence are not uncommon and include several well-described associations, such as sclerosing cholangitis with inflammatory bowel disease. Liver damage may also result from the effects of drugs used to treat GI diseases, for example, the hepatotoxicity of immunomodulatory therapies. This review highlights the important features of the hepatic and biliary abnormalities associated with 3 common pediatric GI conditions: inflammatory bowel disease, celiac disease, and cystic fibrosis.
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Thin LWY, Lawrance IC, Spilsbury K, Kava J, Olynyk JK. Detection of liver injury in IBD using transient elastography. J Crohns Colitis 2014; 8:671-7. [PMID: 24529605 DOI: 10.1016/j.crohns.2013.12.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 11/14/2013] [Accepted: 12/12/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Up to 5% of inflammatory bowel disease (IBD) patients are thought to have clinically significant liver disease due to multifactorial causes, however, this figure may be an underestimate due to reliance on abnormal liver tests (LTs) and/or liver biopsies. AIMS Our aim was to evaluate the prevalence of clinically significant liver disease in IBD patients as defined by an increased liver stiffness measurement (LS) ≥8kPa using transient elastography (TE). METHODS 110 IBD patients, and 55 non-IBD control subjects, had their LS recorded using FibroScan® (EchoSense, Paris, France) by a single blinded operator trained in TE. RESULTS 71 Crohn's disease and 39 ulcerative colitis subjects were included. All demographic variables were similar between the IBD and control groups apart from a significantly higher proportion of IBD patients who smoked (17.3% vs 3.6%, P=0.013). Seven IBD patients (6.4%) had an LS over 8 kPa and 3 had persistently elevated LS 6 months later. One patient had compensated cirrhosis. No significant differences in overall LS were observed between the IBD and control groups. Increased BMI and age, however, were independently associated with a higher LS in the IBD but not in the control group (P<0.001 and 0.010 respectively). CONCLUSION Using TE, the prevalence of clinically significant liver disease in IBD patients is low. The association of increased BMI and age with increased LS in IBD suggests fatty liver disease being the prevailing aetiology in these patients.
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Affiliation(s)
- L W Y Thin
- Centre for Inflammatory Bowel Diseases, Fremantle Hospital, Fremantle, WA, Australia; Department of Gastroenterology, Fremantle Hospital, Fremantle, WA, Australia
| | - I C Lawrance
- Centre for Inflammatory Bowel Diseases, Fremantle Hospital, Fremantle, WA, Australia; University Department of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, WA, Australia; Department of Gastroenterology, Fremantle Hospital, Fremantle, WA, Australia.
| | - K Spilsbury
- Centre for Population Health Research, Curtin University, Bentley, WA, Australia
| | - J Kava
- Department of Gastroenterology, Fremantle Hospital, Fremantle, WA, Australia
| | - J K Olynyk
- Department of Gastroenterology, Fremantle Hospital, Fremantle, WA, Australia; Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, WA, Australia
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Abstract
The interaction between inflammatory bowel disease (IBD) and hepatobiliary manifestations represents a classic example of liver-gut crosstalk. The importance of liver-gut crosstalk in IBD is demonstrated in the pathogenesis and outcome of primary sclerosing cholangitis (PSC) in IBD patients. Immunoglobulin G4-associated cholangitis (IAC), which has recently been described in UC patients, may also illustrate the significance of gut-liver interaction in these patients. Presence of these hepatobiliary manifestations influences the outcome of associated IBD, in particular ulcerative colitis (UC), and vice versa. The pathogenesis of PSC is postulated to be related to gut inflammation in IBD that results in inflammation in the portal tracts (the 'leaky gut'). Enterohepatic circulation of lymphocytes from the gut to the liver is also of potential relevance to PSC pathogenesis and outcomes. The presence of PSC and gut inflammation in IBD influences the course and outcomes of both diseases. Further research is required, to understand the mutual effect of liver-gut crosstalk in the outcomes of UC patients, and highlights the importance of an interdisciplinary approach-involving gastroenterologists, hepatologists, advanced endoscopists and liver transplant surgeons-in the management of these patients.
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Affiliation(s)
- Udayakumar Navaneethan
- Department of Gastroenterology/Hepatology, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Cappello M, Randazzo C, Bravatà I, Licata A, Peralta S, Craxì A, Almasio PL. Liver Function Test Abnormalities in Patients with Inflammatory Bowel Diseases: A Hospital-based Survey. CLINICAL MEDICINE INSIGHTS. GASTROENTEROLOGY 2014; 7:25-31. [PMID: 24966712 PMCID: PMC4069044 DOI: 10.4137/cgast.s13125] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 01/05/2014] [Accepted: 01/06/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Inflammatory bowel diseases (IBD) are frequently associated with altered liver function tests (LFTs). The causal relationship between abnormal LFTs and IBD is unclear. The aim of our study was to evaluate the prevalence and etiology of LFTs abnormalities and their association with clinical variables in a cohort of IBD patients followed up in a single center. MATERIALS AND METHODS A retrospective review was undertaken of all consecutive IBD in- and outpatients routinely followed up at a single referral center. Clinical and demographic parameters were recorded. Subjects were excluded if they had a previous diagnosis of chronic liver disease. LFT abnormality was defined as an increase in aspartate aminotransferase, (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT), or total bilirubin. RESULTS A cohort of 335 patients (179 males, mean age 46.0 ± 15.6 years) was analyzed. Abnormal LFTs were detected in 70 patients (20.9%). In most cases, the alterations were mild and spontaneously returned to normal values in about 60% of patients. Patients with abnormal LFTs were less frequently on treatment with aminosalicylates (22.8 vs. 36.6%, P = 0.04). The most frequent cause for transient abnormal LFTs was drug-induced cholestasis (34.1%), whereas fatty liver was the most frequent cause of persistent liver damage (65.4%). A cholestatic pattern was found in 60.0% of patients and was mainly related to older age, longer duration of disease, and hypertension. CONCLUSIONS The prevalence of LFT abnormalities is relatively high in IBD patients, but the development of severe liver injury is exceptional. Moreover, most alterations of LFTs are mild and spontaneously return to normal values. Drug-induced hepatotoxicity and fatty liver are the most relevant causes of abnormal LFTs in patients with IBD.
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Affiliation(s)
- Maria Cappello
- Gastroenterology and Hepatology Section, Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
| | - Claudia Randazzo
- Gastroenterology and Hepatology Section, Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
| | - Ivana Bravatà
- Gastroenterology and Hepatology Section, Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
| | - Anna Licata
- Gastroenterology and Hepatology Section, Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
| | - Sergio Peralta
- Gastroenterology and Hepatology Section, Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
| | - Antonio Craxì
- Gastroenterology and Hepatology Section, Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
| | - Piero Luigi Almasio
- Gastroenterology and Hepatology Section, Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
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Navaneethan U, Venkatesh PGK, Choudhary M, Shen B, Kiran RP. Elevated immunoglobulin G4 level is associated with reduced colectomy-free survival in patients with primary sclerosing cholangitis and ulcerative colitis. J Crohns Colitis 2013; 7:e35-41. [PMID: 22554774 DOI: 10.1016/j.crohns.2012.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Revised: 04/08/2012] [Accepted: 04/08/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Patients with primary sclerosing cholangitis (PSC) and elevated immunoglobulin (Ig) G4 have been shown to have more severe disease with a shorter time to orthotopic liver transplantation (OLT). The aim of the study was to investigate the clinical outcomes of PSC and UC in patients with elevated serum IgG4. METHODS We analyzed data from 50 patients with PSC and known serum levels of IgG4. They were divided into groups called high IgG4 (>112 IU/L; n = 10) or normal IgG4 (n = 40). We compared the requirement of OLT and colectomy between groups. RESULTS High IgG4 was found in 10 PSC patients (20%). UC was associated in 9/10 patients with high IgG4 vs. 32/40 patients with normal IgG4 (p=0.67). Patients with high IgG4 were younger at PSC diagnosis (28.1 ± 13.9 vs. 37.6 ± 13.4 years, P=0.04), more likely to have backwash ileitis (7/9 vs. 12/32, P < 0.001) and UC flares (median of 5.5 vs. 1.5, P = 0.02). Kaplan-Meier curve analysis showed that patients with elevated IgG4 had reduced colectomy-free survival than patients with normal IgG4 (Log Rank p < 0.001). The median time to colectomy was 5 years from UC diagnosis in high IgG4 group vs. 12 years in the normal IgG4 group (p = 0.01). CONCLUSIONS Elevated IgG4 was seen in a small number of PSC patients. Most of these patients had associated UC, were younger at the time of PSC diagnosis, more likely to have backwash ileitis and had reduced colectomy-free survival than patients with normal IgG4.
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Affiliation(s)
- Udayakumar Navaneethan
- Department of Gastroenterology, Digestive disease Institute, The Cleveland Clinic, Cleveland, OH 44195, USA.
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Navaneethan U, Venkatesh PGK, Lashner BA, Remzi FH, Shen B, Kiran RP. Temporal trends in colon neoplasms in patients with primary sclerosing cholangitis and ulcerative colitis. J Crohns Colitis 2012; 6:845-51. [PMID: 22398080 DOI: 10.1016/j.crohns.2012.01.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 01/10/2012] [Accepted: 01/15/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Surveillance for colon cancer is recommended in patients with primary sclerosing cholangitis (PSC) and ulcerative colitis (UC). It is unclear whether characteristics of colon neoplasia have changed over time. The aim of the study was to examine the temporal trends in colon neoplasia in patients with PSC and UC. METHODS A total of 167 patients followed up at our institution between 1985 and 2011, 55 of these with neoplasia detected on colonoscopic biopsy were identified. Characteristics of patients with colon neoplasia in PSC-UC were studied for two different time periods: 1985-1998 (early cohort) compared to 1999-2011 (recent cohort). RESULTS The median age at diagnosis of colon neoplasms was 53 years (median IQR, 43-63). The baseline characteristics were similar in both cohorts. The colonic neoplasms that developed in PSC-UC patients were spread throughout the colon on colonoscopy, while there was predominant right sided distribution on colectomy in both cohorts. (81.7% vs. 18.3%, p<0.001) Compared to the recent cohort, both the PSC (17 vs. 11 years, p=0.02) and UC duration (20 vs. 12 years, p=0.02) were longer in the early cohort. There were no differences in the grades and stages of cancer diagnosis. In addition, no differences in transplant-free survival or UC characteristics were revealed. CONCLUSIONS With annual colonoscopic surveillance, dysplasia and cancer in patients with a combined diagnosis of PSC//UC is being diagnosed in patients with a shorter duration of these conditions. The nature and the location of neoplasia have, however, not changed.
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Affiliation(s)
- Udayakumar Navaneethan
- Digestive Disease Institute, Department of Gastroenterology, The Cleveland Clinic, Cleveland, OH, USA.
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Investigative MRI cholangiopancreatography for primary sclerosing cholangitis-type lesions in children with IBD. J Pediatr Gastroenterol Nutr 2012; 55:308-13. [PMID: 22569526 DOI: 10.1097/mpg.0b013e31825bb3dc] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of the study was to estimate the frequency of primary sclerosing cholangitis (PSC)-type lesions in children with inflammatory bowel disease (IBD) by means of magnetic resonance cholangiopancreatography (MRCP), and to investigate the association between a series of easily applicable data on the one hand and the presentation of such lesions at MRCP on the other hand. METHODS Collected demographic, laboratory, and magnetic resonance enterography data from the records of 73 children with IBD were cross-sectionally related to the MRCP-based diagnosis. RESULTS Around the time of MRCP, the distribution of IBD subtypes was 64.4%, 24.7%, and 11% for Crohn disease, indeterminate colitis, and ulcerative colitis, respectively. A total of 11 patients (15.1%) were identified with PSC-type lesions. Demographic and magnetic resonance enterography data were unrelated to the MRCP outcome. Biochemical abnormalities were of low prevalence (<50%) among patients with PSC. The abnormality prevalences of aspartate transaminase, alanine transaminase, and γ-glutamyl transferase were significantly higher in the PSC group, both at initial diagnosis of IBD and at the time of MRCP. Less-consistent results were documented for bilirubin and alkaline phosphatase, especially at initial diagnosis of IBD. CONCLUSIONS The abnormality prevalences of aspartate transaminase, alanine transaminase, and γ-glutamyl transferase were significantly higher in the PSC group. Nevertheless, PSC-type lesions frequently occur in pediatric IBD, even if the biochemical profile is hardly indicative of this probability.
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Srivastava B, Mells GF, Cordell HJ, Muriithi A, Brown M, Ellinghaus E, Franke A, Karlsen TH, Sandford RN, Alexander GJ, Chapman RW, Rushbrook SM, Melum E. Fine mapping and replication of genetic risk loci in primary sclerosing cholangitis. Scand J Gastroenterol 2012; 47:820-6. [PMID: 22554193 DOI: 10.3109/00365521.2012.682090] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by progressive inflammation and fibrosis of the bile ducts eventually leading to biliary cirrhosis. Recent genetic studies in PSC have identified associations at 2q13, 2q35, 3p21, 4q27, 13q31 and suggestive association at 10p15. The aim of this study was to further characterize and refine the genetic architecture of PSC. METHODS We analyzed previously reported associated SNPs at four of these non-HLA loci and 59 SNPs tagging the IL-2/IL-21 (4q27) and IL2RA (10p15) loci in 992 UK PSC cases and 5162 healthy UK controls. RESULTS The most associated SNPs identified were rs3197999 (3p21 (MST1), p = 1.9 × 10⁻⁶, OR(A vs G) = 1.28, 95% CI (1.16-1.42)); rs4147359 (10p15 (IL2RA), p = 2.6 × 10⁻⁴, OR(A vs G) = 1.20, 95% CI (1.09-1.33)) and rs12511287 (4q27 (IL-2/IL-21), p = 3.0 × 10⁻⁴, OR(A vs T) = 1.21, 95% CI (1.09-1.35)). In addition, we performed a meta-analysis for selected SNPs using published summary statistics from recent studies. We observed genome-wide significance for rs3197999 (3p21 (MST1), P (combined) = 3.8 × 10⁻¹²) and rs4147359 (10p15 (IL2RA), P (combined) = 1.5 × 10⁻⁸). CONCLUSION We have for the first time confirmed the association of PSC with genetic variants at 10p15 (IL2RA) locus at genome-wide significance and replicated the associations at MST1 and IL-2/IL-21 loci in a large homogeneous UK population. These results strongly implicate the role of IL-2/IL2RA pathway in PSC and provide further confirmation of MST1 association.
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Affiliation(s)
- Brijesh Srivastava
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, UK
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Navaneethan U, G K Venkatesh P, Lashner BA, Lopez R, Kiran RP, Shen B. Severity of primary sclerosing cholangitis and its impact on the clinical outcome of Crohn's disease. J Crohns Colitis 2012; 6:674-80. [PMID: 22398102 DOI: 10.1016/j.crohns.2011.11.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 11/25/2011] [Accepted: 11/25/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Crohn's disease (CD) is associated with primary sclerosing cholangitis (PSC). The aim of the study was to study the association between the severity of PSC and clinical outcome of CD, comparing the course of CD in patients with PSC not needing orthotopic liver transplantation (OLT) and those requiring OLT. METHODS A total of 41 patients with PSC and CD seen at the Cleveland Clinic between 1985 and 2011 were included in this study. Clinical and demographic variables were obtained regarding the outcome of CD in patients with and without OLT. RESULTS Patients with PSC-CD were divided into two groups: 20 without OLT (non-OLT) and 21 with OLT. 18 (85.7%) of patients in the OLT group had pancolitis in contrast to 14 (70%) in the non-OLT group. (p=0.22). There were no significant differences regarding duration of CD, but the duration of PSC was longer in the OLT group [16.0±7.8 vs. 10.3±6.4, p=0.01]. The OLT and non-OLT groups did not differ in the number of CD flares [0 (0, 0) vs. 0 (0, 5), p=0.28) and need for surgery for CD [(6 (28.6%) vs. 9 (45%), p=0.27]. Colon carcinoma and dysplasia were similar in the non-OLT and OLT groups [(4 (20%) vs. 3 (13.2%), p=0.52]. On Cox regression analysis, OLT for PSC [Hazards ratio (HR) 1.2 (95% confidence interval (C.I.): 0.38-3.7, p=0.79] did not impact the risk of colectomy. CONCLUSIONS In contrast to UC, severe PSC requiring OLT does not appear to impact the clinical outcome of CD.
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Affiliation(s)
- Udayakumar Navaneethan
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic, Cleveland, OH, USA.
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Navaneethan U, Venkatesh PGK, Mukewar S, Lashner BA, Remzi FH, McCullough AJ, Kiran RP, Shen B, Fung JJ. Progressive primary sclerosing cholangitis requiring liver transplantation is associated with reduced need for colectomy in patients with ulcerative colitis. Clin Gastroenterol Hepatol 2012; 10:540-6. [PMID: 22245961 DOI: 10.1016/j.cgh.2012.01.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 12/28/2011] [Accepted: 01/01/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS We investigated the association between the severity of primary sclerosing cholangitis (PSC) and clinical outcomes of patients with ulcerative colitis (UC) on the basis of need for colectomy. METHODS We analyzed data from 167 patients with PSC and UC who were followed from 1985 to 2011. Patients with PSC and UC were divided into groups that received orthotopic liver transplantation (OLT) (n = 86) or did not (non-OLT, n = 81). Clinical and demographic variables were obtained, and patients were followed until they received OLT or the date of their last clinical visit. RESULTS The OLT group had significantly more subjects with less severe symptoms of UC (59, 68.6%) than the non-OLT group (12, 14.8%; P < .001). The subjects in the OLT group had a median of 0 UC flares compared with 3 in the non-OLT group (P < .001); fewer subjects in the OLT group required use of azathioprine or mercaptopurine (1, 1.2%), compared with the non-OLT group (14, 17.3%; P = .006). More subjects in the non-OLT group required colectomies (61, 75.3%) than in the OLT group (23, 26.7%; P < .001). On the basis of Cox regression analysis, OLT for PSC independently reduces the need for colectomy (hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.25-0.75; P = .003), as does a high Mayo risk score at diagnosis (HR, 0.52; 95% CI, 0.37-0.72; P < .001). Development of colon neoplasia increased the risk for colectomy (HR, 2.47; 95% CI, 1.63-3.75; P < .001). CONCLUSIONS Severe progressive PSC that requires liver transplantation appears to reduce the disease activity of UC and the need for colectomy.
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Affiliation(s)
- Udayakumar Navaneethan
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Khan N, Abbas AM, Whang N, Balart LA, Bazzano LA, Kelly TN. Incidence of liver toxicity in inflammatory bowel disease patients treated with methotrexate: a meta-analysis of clinical trials. Inflamm Bowel Dis 2012; 18:359-67. [PMID: 21751301 DOI: 10.1002/ibd.21820] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 06/08/2011] [Indexed: 01/22/2023]
Abstract
BACKGROUND Crohn's disease and ulcerative colitis are chronic debilitating diseases for which there are multiple treatment options. There are limited data on methotrexate's efficacy and safety profile. Our aim was to estimate the hepatotoxicity associated with its use in inflammatory bowel diseases (IBDs). METHODS We systematically searched the Medline, Cochrane Library, Web of Science, and EMBASE databases and manually examined references in selected articles for trials that used methotrexate as a treatment for IBDs. Thirteen trials that fulfilled the inclusion and exclusion criteria were included in the meta-analysis. Information on trial and patient characteristics, use of methotrexate as well as other treatments or placebo, and levels of hepatic aminotransferase enzymes were abstracted by two independent investigators using a standardized form. A random effects model was used to pool the incidence rates of reported abnormalities in hepatic aminotransferases. RESULTS The pooled incidence rate of abnormal hepatic aminotransferase levels (defined as up to a 2-fold increase over the upper limit of the normal range) in patients treated with methotrexate for IBD was 1.4 per 100 person-months, while the rate of hepatotoxicity (defined as greater than a 2-fold over the upper limit of the normal range) was 0.9 per 100 person-months. The rate of withdrawal from treatment due to these abnormalities was 0.8 per 100 person-months. CONCLUSIONS The incidence of methotrexate-related hepatotoxicity as measured by elevation in transaminases and drug withdrawal secondary to elevated transaminases is relatively low.
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Affiliation(s)
- Nabeel Khan
- Section of Gastroenterology and Hepatology at Tulane University Health Sciences Center, New Orleans, Louisiana 70112, USA.
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Shen B, Bennett AE, Navaneethan U, Lian L, Shao Z, Kiran RP, Fazio VW, Remzi FH. Primary sclerosing cholangitis is associated with endoscopic and histologic inflammation of the distal afferent limb in patients with ileal pouch-anal anastomosis. Inflamm Bowel Dis 2011; 17:1890-900. [PMID: 21830267 DOI: 10.1002/ibd.21594] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Accepted: 11/03/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND We hypothesized that patients with primary sclerosing cholangitis (PSC) may have a higher risk for prepouch ileitis in the setting of ileal pouch-anal anastomosis (IPAA). The aim of this study was to compare endoscopic and histologic inflammation in the afferent limb (prepouch ileum) and pouch between IPAA patients with and without PSC. METHODS In all, 39 consecutive inflammatory bowel disease (IBD) and IPAA patients with PSC (study group) were identified and 91 IBD and IPAA patients without PSC (control group) were randomly selected with a 1:2 ratio. Demographic, clinical, endoscopic, and histologic variables were analyzed. RESULTS There were no significant differences in age, gender, and nonsteroidal antiinflammatory drug use between the study and control groups. Twelve (30.8%) patients in the IPAA-PSC group had coexisting autoimmune disorders, in contrast to five (5.5%) patients in the IPAA control group (P < 0.001). More patients in the study group had endoscopic inflammation as demonstrated by the higher Pouchitis Disease Activity Index (PDAI) endoscopic scores of the afferent limb and pouch body than those in the control group (P = 0.02 and P < 0.001, respectively). In addition, more patients with PSC had higher PDAI histologic scores of the afferent limb than those without PSC (P < 0.001). Multivariate analysis showed higher PDAI endoscopy and histology subscores were associated with risk for PSC, with odds ratio 1.34 (95% confidence interval [CI]: 1.34, 3.79) and 1.61 (95% CI: 1.00, 2.58), respectively. CONCLUSIONS Concurrent PSC appears to be associated with a significant prepouch ileitis on endoscopy and histology in patients with IPAA. Pouch patients with long segment of ileitis should be evaluated for PSC.
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Affiliation(s)
- Bo Shen
- Department of Gastroenterology, the Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Navaneethan U, Shen B. Hepatopancreatobiliary manifestations and complications associated with inflammatory bowel disease. Inflamm Bowel Dis 2010; 16:1598-619. [PMID: 20198712 DOI: 10.1002/ibd.21219] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Diseases involving the hepatopancreatobiliary (HPB) system are frequently encountered in patients with inflammatory bowel disease (IBD). Hepatobiliary manifestations constitute some of the most common extraintestinal manifestations of IBD. They appear to occur with similar frequency in patients with Crohn's disease or ulcerative colitis. HPB manifestations may occur in following settings: 1) disease possibly associated with a shared pathogenetic mechanism with IBD including primary sclerosing cholangitis (PSC), small-duct PSC/pericholangitis and PSC/autoimmune hepatitis overlap, acute and chronic pancreatitis related to IBD; 2) diseases which parallel structural and physiological changes seen with IBD, including cholelithiasis, portal vein thrombosis, and hepatic abscess; and 3) diseases related to adverse effects associated with treatment of IBD, including drug-induced hepatitis, pancreatitis (purine-based agents), or liver cirrhosis (methotrexate), and reactivation of hepatitis B, and biologic agent-associated hepatosplenic lymphoma. Less common HPB manifestations that have been described in association with IBD include autoimmune pancreatitis (AIP), IgG4-associated cholangitis (IAC), primary biliary cirrhosis (PBC), fatty liver, granulomatous hepatitis, and amyloidosis. PSC is the most significant hepatobiliary manifestation associated with IBD and poses substantial challenges in management requiring a multidisciplinary approach. The natural disease course of PSC may progress to cirrhosis and ultimately require liver transplantation in spite of total proctocolectomy with ileal-pouch anal anastomosis. The association between AIP, IAC, and elevated serum IgG4 in patients with PSC is intriguing. The recently reported association between IAC and IBD may open the door to investigate these complex disorders. Further studies are warranted to help understand the pathogenesis of HPB manifestations associated with IBD, which would help clinicians better manage these patients. An interdisciplinary approach, involving gastroenterologists, hepatologists, and, in advanced cases, general, colorectal, and transplant surgeons is advocated.
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Endoscopic ultrasound elastography as a method for screening the patients with suspected primary sclerosing cholangitis. Eur J Gastroenterol Hepatol 2010; 22:748-53. [PMID: 19494783 DOI: 10.1097/meg.0b013e32832d489f] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Currently, magnetic resonance cholangiography is being used for establishing the diagnosis of primary sclerosing cholangitis, whereas endoscopic retrograde cholangiography is reserved for therapeutic interventions. The aim of this study was to determine the role of endoscopic ultrasound elastography in the detection of inflammatory and fibrotic lesions of the common bile duct. METHODS Linear endoscopic ultrasound elastography of the common bile duct was performed in 41 patients. The patients were divided into two groups: disease group (20 patients with both, primary sclerosing cholangitis and inflammatory bowel disease) and control group (21 patients). Main outcome measurements were diameter, wall thickness and wall qualitative Elasto Score of the common bile duct. RESULTS The disease group consisted of nine females and 11 males, whereas the control group consisted of 13 females and eight males, with no sex differences observed (chi = 0.6, d.f. = 1, P = 0.443). There was no significant difference in the diameter of common bile duct between the studied groups: 4.67+/-1.83 mm in the disease group and 5.88+/-2.47 mm in controls (t = -1.77, d.f. = 39, P = 0.085). Hard or mixed Elasto Score was found in 16 patients and four controls, being significantly different compared with the soft Elasto Score found in four patients and 17 controls (chi = 1.8, d.f. = 1, P<0.001). A significant difference was observed in the common bile duct wall thickness: 0.89+/-0.59 mm in the disease group and 0.39+/-0.14 mm in controls (t = 3.75, d.f. = 39, P<0.001). CONCLUSION Endoscopic ultrasound elastography might be a useful noninvasive method in diagnosing primary sclerosing cholangitis.
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