Predictive factors of response to infliximab therapy in Brazilian inflammatory bowel disease patients

Background

Biological therapies have revolutionized the treatment of patients with inflammatory bowel disease (IBD). Infliximab (IFX) has been shown to be effective in inducing and maintaining remission in patients with Crohn's disease and ulcerative colitis. However, about one-third of the patients are primary non-responders, and up to half can lose response over time. Hence, it is important to assess which factors are related to treatment failure.

Objectives

We aimed to identify factors predicting clinical and endoscopic remission with IFX treatment during maintenance therapy in a Brazilian IBD referral center.

Design

We conducted a cross-sectional study to describe demographic, clinical, and IBD therapy-related characteristics of IBD patients treated with IFX for at least 6 months in a Brazilian referral center. Subsequently, we evaluated factors associated with clinical and endoscopic remission (primary and secondary outcomes, respectively).

Methods

We used descriptive statistics to summarize the essential demographic and clinical characteristics of the population. The association of sociodemographic and clinical variables with outcomes was analyzed using multivariable logistic regression.

Results

A total of 131 IBD patients (the mean age 41.7 years) were enrolled in this study. Clinical and endoscopic remission were observed in 79.4% and 58.2% of the patients, respectively. In the multivariable analysis, IFX therapy duration and higher albumin levels increased the likelihood of clinical remission, while previous surgery decreased its chance. Prior use of adalimumab and higher C-reactive protein levels reduced the likelihood of endoscopic remission.

Conclusion

In summary, this study has enhanced our understanding of the predictive factors of treatment response to IFX in a well-characterized Brazilian IBD population.

Trial registration

4.254.501 and 2.903.748.

Gastric and Duodenal Fistulas in Crohn's Disease, a Surgical Challenge: Report of 5 Cases and a Review of the Literature

BACKGROUND Fistulas involving the stomach and duodenum in Crohn's disease are rare (occurring in less than 1% of patients). Here, we reviewed registers from 855 patients with Crohn's disease treated in our service from January 2007 to December 2020 and found 4 cases of duodenal fistula and 1 case of gastric fistula. CASE REPORT The fistula origin was in the ileocolic segment in all cases, and all of the patients underwent preoperative optimization with improvement of nutritional status and infection control. They then underwent surgical treatment with resection of the affected segment and duodenal or gastric closure with covering by an omental patch. One case of a duodenal fistula was complicated by duodenal dehiscence. This was treated surgically with duodenojejunostomy. Each of the other patients had an uneventful postoperative course. All patients were successfully cured of their gastroduodenal fistulas, and at the time of this publication, none of them died or had fistula recurrence. CONCLUSIONS Fistulas with the involvement of the stomach and duodenum in patients with Crohn's disease are almost always due to inflammation in the ileum, colon, or previous ileocolic anastomosis. Management of this situation is complex and often requires clinical and surgical assistance; preoperative optimization of the patient's general condition can improve the surgical results. The surgical approach is based on resection of the affected segment and gastric or duodenal closure with covering by an omental patch. Gastrojejunostomy or duodenojejunostomy can be performed in selected patients with larger defects and minor jejunal disease. To prevent recurrence, prophylactic therapy with anti-TNF agents and early endoscopic surveillance are also essential for successful treatment.

A Sessile Serrated Lesion Overlying a Submucosal Colonic Lipoma: An Endoscopic Rarity Identified Using Artificial Intelligence

BACKGROUND Lipomas are benign, slow-growing mesenchymal neoplasms, more prevalent in females, with a peak incidence in the fifth to sixth decades of life. Generally, due to their low clinical relevance, they receive little attention in the literature. Uncommon in the colon, lipomas are most often identified as an incidentaloma in asymptomatic patients during colonoscopy, and overlapping with epithelial lesions is a rare finding. Serrated polyps used to be considered as hyperplastic polyps without any malignant potential; however, currently, the serrated pathway accounts for one-third of all colorectal cancers. Here, we describe a rare case of a sessile serrated lesion on a submucosal lipoma identified with the aid of artificial intelligence. CASE REPORT A 60-year-old woman underwent screening colonoscopy for colorectal cancer after a positive fecal immunochemical test. A high-definition colonoscopy with the aid of artificial intelligence (Fujifilm CAD EYE) was performed. A flat lesion at the right colon was diagnosed with white-light endoscopy simultaneously identified by artificial intelligence, which classified the lesion as hyperplastic. Resection was performed through mucosectomy, and a sign of naked fat was observed at the base of the resected lesion. Histopathology of the specimen characterized a submucosal lipoma associated with a sessile serrated lesion. CONCLUSIONS We describe a rare case of sessile serrated lesion on a colon lipoma, identified with the aid of artificial intelligence. We carried out a brief literature review and discussed the main findings and aspects related to the literature.

Efficacy of Early Optimization of Infliximab Guided by Therapeutic Drug Monitoring during Induction-A Prospective Trial

Therapeutic drug monitoring (TDM) during induction therapy with anti-tumor necrosis factor drugs has emerged as a strategy to optimize response to these biologics and avoid undesired outcomes related to inadequate drug exposure. This study aimed to describe clinical, biological, and endoscopic remission rates at six months in Brazilian inflammatory bowel disease (IBD) patients following a proactive TDM algorithm guided by IFX trough levels (ITL) and antibodies to IFX (ATI) levels during induction, at week six. A total of 111 IBD patients were prospectively enrolled, excluding those previously exposed to the drug. ITL ≥ 10 μg/mL was considered optimal. Patients with suboptimal ITL (<10 µg/mL) were guided according to ATI levels. Those who presented ATI ≤ 200 ng/mL underwent dose intensification in the maintenance phase, and patients with ATI > 200 ng/mL discontinued IFX. In our study, proactive TDM was associated with persistence in the IFX rate at six months of 82.9%. At that time, rates of clinical, biological, and endoscopic remission in patients under IFX treatment were 80.2%, 73.9%, and 48.1%, respectively. Applying a simplified TDM-guided algorithm during induction seems feasible and can help improve patients' outcomes in clinical practice.

Neurotuberculosis in a Patient with Ulcerative Colitis Using Long-Term Adalimumab: A Rare Case

BACKGROUND Tuberculosis (TB), a global public health problem, is a disease with a high incidence and prevalence worldwide. The risk of developing TB increases after starting anti-tumor necrosis factor (TNF) therapy in the management of ulcerative colitis (UC). Isolated neurotuberculosis (NTB) without other manifestations is a rare form of infection in these patients. This article reports a case of a severe UC patient with isolated NTB following long-term therapy with adalimumab and discusses the clinical aspects, diagnosis, management, and prognosis. CASE REPORT A 34-year-old female patient with severe UC with pancolitis reported continuous and progressive holocranial headaches associated with a daily fever of 38°C and night sweats after 4 years of using adalimumab and after being in deep remission. Annually, she was screened for latent TB with chest X-rays and a Mantoux tuberculin skin test, and she always had negative results for TB. On cerebral magnetic resonance imaging with post-contrast sequences, small cortical lesions in the left frontal lobe and 2 larger lesions were visualized and were suggestive of tuberculomas. The initial management consisted of the suspension of immunosuppressive therapy and treatment with rifampicin, isoniazid, ethambutol, pyrazinamide, and prednisone. The patient showed clinical and neurological improvement and was clinically asymptomatic, with no changes in laboratory tests. Also, she had no neurological sequelae and was taking maintenance therapy with prednisone as indicated by the neurologist. CONCLUSIONS Early recognition of symptoms of neurological involvement of TB, suspension of anti-TNF and adequate treatment are fundamental steps to prevent complications.

The relationship of major depressive disorder with Crohn's disease activity

INTRODUCTION

Crohn's disease (CD) has been related to an increased prevalence of psychiatric disorders and suicide risk (SR). However, the nature of their relationship still deserves clarification. The aim of this study is to assess the prevalence of major depressive disorder (MDD) in patients with CD, and to investigate the relationship between MDD and CD outcomes.

METHODS

A cross-sectional study involving CD patients was performed. CD activity was evaluated by the Harvey-Bradshaw index and CD phenotype by the Montreal classification. The presence of MDD was assessed by the Patient Health Questionnaire score-9 (PHQ-9). Sociodemographic data and other characteristics were retrieved from electronic medical records.

RESULTS

283 patients with CD were included. The prevalence of MDD was 41.7%. Females had a risk of MDD 5.3 times greater than males. CD disease duration was inversely correlated with MDD severity. Individuals with active CD were more likely to have MDD (OR = 796.0; 95% CI 133.7‒4738.8) than individuals with CD remission. MDD was more prevalent in inflammatory behavior (45.5%) and there were no statistical differences regarding the disease location. 19.8% of the sample scored positive for SR.

CONCLUSION

The present results support data showing an increased prevalence of MDD in individuals with CD. Additionally, it indicates that MDD in CD might be related to the activity of CD. Prospective studies are warranted to confirm these results and to address whether MDD leads to CD activity, CD activity leads to MDD or both ways are existent.

SURGICAL MANAGEMENT OF ADULT CROHN'S DISEASE AND ULCERATIVE COLITIS PATIENTS: A CONSENSUS FROM THE BRAZILIAN ORGANIZATION OF CROHN'S DISEASE AND COLITIS (GEDIIB)

BACKGROUND

Despite optimized medical therapy, contemporary risk of surgery in inflammatory bowel diseases (IBD) after 10 years of diagnosis is 9.2% in patients with ulcerative colitis (UC) and 26.2% in Crohn's disease, (CD) in the biological era.

OBJECTIVE

This consensus aims to detail guidance to the most appropriate surgical procedures in different IBD scenarios. In addition, it details surgical indications and perioperative management of adult patients with CD and UC.

METHODS

Our consensus was developed by colorectal surgeons and gastroenterologists representing the Brazilian Study Group of Inflammatory Bowel Diseases (GEDIIB), with the Rapid Review methodology being conducted to support the recommendations/statements. Surgical recommendations were structured and mapped according to the disease phenotypes, surgical indications, and techniques. After structuring the recommendations/statements, the modified Delphi Panel methodology was used to conduct the voting by experts in IBD surgery and gastroenterology. This consisted of three rounds: two using a personalized and anonymous online voting platform and one face-to-face presential meeting. Whenever participants did not agree with specific statements or recommendations, an option to outline possible reasons was offered to enable free-text responses and provide the opportunity for the experts to elaborate or explain disagreement. The consensus of recommendations/statements in each round was considered to have been reached if there was ≥80% agreement.

RESULTS AND CONCLUSION

This consensus addressed the most relevant information to guide the decision-making process for adequate surgical management of CD and UC. It synthesizes recommendations developed from evidence-based statements and state-of-art knowledge. Surgical recommendations were structured and mapped according to the different disease phenotypes, indications for surgery and perioperative management. Specific focus of our consensus was given to elective and emergency surgical procedures, determining when to indicate surgery and which procedures may be the more appropriate. The consensus is targeted to gastroenterologists and surgeons interested in the treatment and management of adult patients with CD or UC and supports decision-making of healthcare payors, institutional leaders, and/or administrators.

Local treatment of colostomy prolapse with the MESH STRIP technique: A novel and highly efficient day hospital technique

OBJECTIVE

Stoma prolapse is an intussusception of the bowel through a mature stoma. It can be caused by increased intra-abdominal pressure, excessively mobile bowel mesentery and/or a large opening in the abdominal wall at the time of stoma formation. It occurs predominantly in loop stomas, and correction methods include conservative modalities, such as local reduction to the prolapsed bowel, or surgical treatment. The purpose of this study was to describe our experience with the treatment of colostomy prolapse using a novel mesh strip technique.

METHODS

Between February 2009 and March 2018, ten consecutive male patients underwent correction of colostomy prolapse under local anesthesia by peristomal placement of a polypropylene mesh strip. Operation time, short- and long-term complications, and recurrence rates were recorded and analyzed.

RESULTS

No postoperative complications, morbidity or mortality were observed. The median length of the prolapse ranged from 6-20 cm, and the median operative time was 30 minutes. The median duration of follow-up was 25 months (range, 12-89 months). No relapse, mesh strip extrusion, local infection or granuloma formation were found.

CONCLUSION

A simple, fast, and low-cost operation under local anesthesia using a mesh strip is a valuable option to treat colostomy prolapse.