1
|
Leddin D, Singh H, Armstrong D, Cheyne K, Galts C, Igoe J, Leontiadis G, McGrath J, Pray C, Sadowski D, Shahidi N, Sinclair P, Tse F, Yanofsky R. The Canadian Association of Gastroenterology's New Climate Change Committee. J Can Assoc Gastroenterol 2024; 7:135-136. [PMID: 38596799 PMCID: PMC10999766 DOI: 10.1093/jcag/gwae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Affiliation(s)
- Desmond Leddin
- Division of Digestive Care & Endoscopy, Department of Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Harminder Singh
- Section of Gastroenterology, Deparment of Internal Medicine, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
| | - David Armstrong
- Division of Gastroenterology, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Kelsey Cheyne
- Canadian Digestive Health Foundation, Oakville, ON L6M 4J2, Canada
| | - Ciaran Galts
- Division of Gastroenterology, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - John Igoe
- Division of Digestive Care & Endoscopy, Department of Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | | | - Jerry McGrath
- Department of Medicine, Memorial University, St. John’s, NL A1B 3V6, Canada
| | - Cara Pray
- Division of Gastroenterology, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Daniel Sadowski
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2G3, Canada
| | - Neal Shahidi
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | | | - Frances Tse
- Division of Gastroenterology, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Russell Yanofsky
- Division of Gastroenterology, University of Toronto, Toronto, ON M5S 1A1, Canada
| |
Collapse
|
2
|
Tomlinson E, Pardo Pardo J, Sivesind T, Szeto MD, Laughter M, Foxlee R, Brown M, Skoetz N, Dellavalle RP, Va Franco J, Clarke M, Krentel A, Reveiz L, Saran A, Tse F, A Wells G, Boyle R, Hilgart J, Ndi EEA, Welch V, Petkovic J, Tugwell P. Prioritising Cochrane reviews to be updated with health equity focus. Int J Equity Health 2023; 22:81. [PMID: 37147653 PMCID: PMC10161173 DOI: 10.1186/s12939-023-01864-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 03/16/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND The prioritisation of updating published systematic reviews of interventions is vital to prevent research waste and ensure relevance to stakeholders. The consideration of health equity in reviews is also important to ensure interventions will not exacerbate the existing inequities of the disadvantaged if universally implemented. This study aimed to pilot a priority setting exercise based on systematic reviews of interventions published in the Cochrane Library, to identify and prioritise reviews to be updated with a focus on health equity. METHODS We conducted a priority setting exercise with a group of 13 international stakeholders. We identified Cochrane reviews of interventions that showed a reduction in mortality, had at least one Summary of Findings table and that focused on one of 42 conditions with a high global burden of disease from the 2019 WHO Global Burden of Disease report. This included 21 conditions used as indicators of success of the United Nations Universal Health Coverage in attaining the Sustainable Development Goals. Stakeholders prioritised reviews that were relevant to disadvantaged populations, or to characteristics of potential disadvantage within the general population. RESULTS After searching for Cochrane reviews of interventions within 42 conditions, we identified 359 reviews that assessed mortality and included at least one Summary of Findings table. These pertained to 29 of the 42 conditions; 13 priority conditions had no reviews with the outcome mortality. Reducing the list to only reviews showing a clinically important reduction in mortality left 33 reviews. Stakeholders ranked these reviews in order of priority to be updated with a focus on health equity. CONCLUSIONS This project developed and implemented a methodology to set priorities for updating systematic reviews spanning multiple health topics with a health equity focus. It prioritised reviews that reduce overall mortality, are relevant to disadvantaged populations, and focus on conditions with a high global burden of disease. This approach to the prioritisation of systematic reviews of interventions that reduce mortality provides a template that can be extended to reducing morbidity, and the combination of mortality and morbidity as represented in Disability-Adjusted Life Years and Quality-Adjusted Life Years.
Collapse
Affiliation(s)
- Eve Tomlinson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Jordi Pardo Pardo
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Ottawa Methods Centre, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Torunn Sivesind
- Department of Dermatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Mindy D Szeto
- Department of Dermatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Melissa Laughter
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, USA
| | | | - Michael Brown
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Nicole Skoetz
- Evidence-based Medicine, Department I of Internal Medicine, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Robert P Dellavalle
- University of Colorado School of Medicine, Aurora, CO, USA
- Dermatology Service, Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, CO, USA
| | - Juan Va Franco
- Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Mike Clarke
- Cochrane Methodology Review Group; Queen's University Belfast, Royal Hospitals, Grosvenor Road, BT12 6BJ, Belfast, UK
| | - Alison Krentel
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Bruyere Research Institute, Ottawa, Canada
| | - Ludovic Reveiz
- Knowledge Translation Program, Evidence and Intelligence for Action in Health Department, Pan American Health Organization, Washington, DC, USA
| | | | - Frances Tse
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - George A Wells
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Robert Boyle
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Jennifer Hilgart
- Evidence Production & Methods Directorate, Cochrane Central Executive Team, London, UK
| | | | - Vivian Welch
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Bruyere Research Institute, Ottawa, Canada
| | | | - Peter Tugwell
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| |
Collapse
|
3
|
Forbes N, Elmunzer BJ, Keswani RN, Hilsden RJ, Hall M, Anderson JT, Arvanitakis M, Chen YI, Duloy A, Elta GH, Maranki JL, Mergener K, Petersen BT, Sethi A, Siersema PD, Smith ZL, Telford JJ, Tse F, Cotton PB, Wani S. Consensus-based development of a causal attribution system for post-ERCP adverse events. Gut 2022; 71:gutjnl-2022-328059. [PMID: 35817552 DOI: 10.1136/gutjnl-2022-328059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/29/2022] [Indexed: 12/08/2022]
Affiliation(s)
- Nauzer Forbes
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rajesh N Keswani
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Robert J Hilsden
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matt Hall
- Biostatistics, Children's Hospital Association, Overland Park, Kansas, USA
| | - John T Anderson
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, Gloucestershire, UK
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology. Erasme Hospital, Universite Libre de Bruxelles, Bruxelles, Bruxelles, Belgium
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Québec, Canada
| | - Anna Duloy
- Division of Gastroenterology and Hepatology, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Grace H Elta
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer L Maranki
- Division of Gastroenterology and Hepatology, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Klaus Mergener
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, New York, USA
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Universiteit Nijmegen, Nijmegen, The Netherlands
| | - Zachary L Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jennifer J Telford
- Department of Medicine, Division of Gastroenterology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Frances Tse
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Peter B Cotton
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| |
Collapse
|
4
|
Tse F, Liu J, Yuan Y, Moayyedi P, Leontiadis GI. Guidewire-assisted cannulation of the common bile duct for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Cochrane Database Syst Rev 2022; 3:CD009662. [PMID: 35349163 PMCID: PMC8963249 DOI: 10.1002/14651858.cd009662.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cannulation techniques have been recognized as being important in causing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, considerable controversy exists about the usefulness of the guidewire-assisted cannulation technique for the prevention of PEP. OBJECTIVES To assess the effectiveness and safety of the guidewire-assisted cannulation technique compared to the conventional contrast-assisted cannulation technique for the prevention of PEP in people undergoing diagnostic or therapeutic ERCP for biliary or pancreatic diseases. SEARCH METHODS For the previous version of this review, we searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL and major conference proceedings, up to February 2012, with no language restrictions. An updated search was performed on 26 February 2021 for the current version of this review. Two clinical trial registries, clinicaltrials.gov and WHO ICTRP, were also searched in this update. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing the guidewire-assisted cannulation technique versus the contrast-assisted cannulation technique in people undergoing ERCP. DATA COLLECTION AND ANALYSIS Two review authors conducted study selection, data extraction, and methodological quality assessment independently. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi² test (P < 0.10) and I² statistic (> 50%). To explore sources of heterogeneity, we conducted a priori subgroup analyses according to trial design, publication type, risk of bias, use of precut sphincterotomy, inadvertent guidewire insertion or contrast injection of the pancreatic duct (PD), use of a PD stent, cannulation device, and trainee involvement in cannulation. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed-effect versus random-effects) and per-protocol analysis. MAIN RESULTS 15 RCTs comprising 4426 participants were included. There was moderate heterogeneity among trials for the outcome of PEP (P = 0.08, I² = 36%). Meta-analyses suggest that the guidewire-assisted cannulation technique probably reduces the risk of PEP compared to the contrast-assisted cannulation technique (RR 0.51, 95% CI 0.36 to 0.72, 15 studies, moderate-certainty evidence). In addition, the guidewire-assisted cannulation technique may result in an increase in primary cannulation success (RR 1.06, 95% CI 1.01 to 1.12, 13 studies, low-certainty evidence), and probably reduces the need for precut sphincterotomy (RR 0.79, 95% CI 0.64 to 0.96, 10 studies, moderate-certainty evidence). Compared to the contrast-assisted cannulation technique, the guidewire-assisted cannulation technique may result in little to no difference in the risk of post-sphincterotomy bleeding (RR 0.87, 95% CI 0.49 to 1.54, 7 studies, low-certainty evidence) and perforation (RR 0.93, 95% CI 0.11 to 8.23, 8 studies, very low-certainty evidence). Procedure-related mortality was reported by eight studies, and there were no cases of deaths in both arms (moderate-certainty evidence). Subgroup analyses suggest that the heterogeneity for the outcome of PEP could be explained by differences in trial design. The results were robust in sensitivity analyses. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that the guidewire-assisted cannulation technique probably reduces the risk of PEP compared to the contrast-assisted cannulation technique. There is low-certainty evidence that the guidewire-assisted cannulation technique may result in an increase in primary cannulation success. There is low- and very low-certainty evidence that the guidewire-assisted cannulation technique may result in little to no difference in the risk of bleeding and perforation. No procedure-related deaths were reported. Therefore, the guidewire-assisted cannulation technique appears to be superior to the contrast-assisted cannulation technique considering the certainty of evidence and the balance of benefits and harms. However, the routine use of guidewires in biliary cannulation will be dependent on local expertise, availability, and cost. Future research should assess the effectiveness and safety of the guidewire-assisted cannulation technique in the context of other pharmacologic or non-pharmacologic interventions for the prevention of PEP.
Collapse
Affiliation(s)
- Frances Tse
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, Hamilton, Canada
| | - Jasmine Liu
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Yuhong Yuan
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
| | - Paul Moayyedi
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, Hamilton, Canada
| | - Grigorios I Leontiadis
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, Hamilton, Canada
| |
Collapse
|
5
|
Kanno T, Yuan Y, Tse F, Howden CW, Moayyedi P, Leontiadis GI. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev 2022; 1:CD005415. [PMID: 34995368 PMCID: PMC8741303 DOI: 10.1002/14651858.cd005415.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Upper gastrointestinal (GI) bleeding is a common reason for emergency hospital admission. Proton pump inhibitors (PPIs) reduce gastric acid production and are used to manage upper GI bleeding. However, there is conflicting evidence regarding the clinical efficacy of proton pump inhibitors initiated before endoscopy in people with upper gastrointestinal bleeding. OBJECTIVES To assess the effects of PPI treatment initiated prior to endoscopy in people with acute upper GI bleeding. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase and CINAHL databases and major conference proceedings to October 2008, for the previous versions of this review, and in April 2018, October 2019, and 3 June 2021 for this update. We also contacted experts in the field and searched trial registries and references of trials for any additional trials. SELECTION CRITERIA We selected randomised controlled trials (RCTs) that compared treatment with a PPI (oral or intravenous) versus control treatment with either placebo, histamine-2 receptor antagonist (H2RA) or no treatment, prior to endoscopy in hospitalised people with uninvestigated upper GI bleeding. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed study eligibility, extracted study data and assessed risk of bias. Outcomes assessed at 30 days were: mortality (our primary outcome), rebleeding, surgery, high-risk stigmata of recent haemorrhage (active bleeding, non-bleeding visible vessel or adherent clot) at index endoscopy, endoscopic haemostatic treatment at index endoscopy, time to discharge, blood transfusion requirements and adverse effects. We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included six RCTs comprising 2223 participants. No new studies have been published after the literature search performed in 2008 for the previous version of this review. Of the included studies, we considered one to be at low risk of bias, two to be at unclear risk of bias, and three at high risk of bias. Our meta-analyses suggest that pre-endoscopic PPI use may not reduce mortality (OR 1.14, 95% CI 0.76 to 1.70; 5 studies; low-certainty evidence), and may reduce rebleeding (OR 0.81, 95% CI 0.62 to 1.06; 5 studies; low-certainty evidence). In addition, pre-endoscopic PPI use may not reduce the need for surgery (OR 0.91, 95% CI 0.65 to 1.26; 6 studies; low-certainty evidence), and may not reduce the proportion of participants with high-risk stigmata of recent haemorrhage at index endoscopy (OR 0.80, 95% CI 0.52 to 1.21; 4 studies; low-certainty evidence). Pre-endoscopic PPI use likely reduces the need for endoscopic haemostatic treatment at index endoscopy (OR 0.68, 95% CI 0.50 to 0.93; 3 studies; moderate-certainty evidence). There were insufficient data to determine the effect of pre-endoscopic PPI use on blood transfusions (2 studies; meta-analysis not possible; very low-certainty evidence) and time to discharge (1 study; very low-certainty evidence). There was no substantial heterogeneity amongst trials in any analysis. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that PPI treatment initiated before endoscopy for upper GI bleeding likely reduces the requirement for endoscopic haemostatic treatment at index endoscopy. However, there is insufficient evidence to conclude whether pre-endoscopic PPI treatment increases, reduces or has no effect on other clinical outcomes, including mortality, rebleeding and need for surgery. Further well-designed RCTs that conform to current standards for endoscopic haemostatic treatment and appropriate co-interventions, and that ensure high-dose PPIs are only given to people who received endoscopic haemostatic treatment, regardless of initial randomisation, are warranted. However, as it may be unrealistic to achieve the optimal information size, pragmatic multicentre trials may provide valuable evidence on this topic.
Collapse
Affiliation(s)
- Takeshi Kanno
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Division of Gastroenterology, Tohoku University Hospital, Sendai, Japan
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yuhong Yuan
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| | - Frances Tse
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| | - Colin W Howden
- Division of Gastroenterology, University of Tennessee, Memphis, TN, USA
| | - Paul Moayyedi
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| | - Grigorios I Leontiadis
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| |
Collapse
|
6
|
Forbes N, Frehlich L, Borgaonkar M, Leontiadis GI, Tse F. Canadian Association of Gastroenterology (CAG) Position Statement on the Use of Hyoscine- n-butylbromide (Buscopan) During Gastrointestinal Endoscopy. J Can Assoc Gastroenterol 2021; 4:259-268. [PMID: 34877465 PMCID: PMC8643672 DOI: 10.1093/jcag/gwab038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/23/2021] [Indexed: 12/21/2022] Open
Abstract
Hyoscine butylbromide, also known as hyoscyamine or scopolamine, and sold under the trade name Buscopan, is an antimuscarinic agent commonly used to induce smooth muscle relaxation and reduce spasmodic activity of the gastrointestinal (GI) tract during endoscopic procedures. However, the balance between desirable and undesirable (adverse) effects is not clear when used during GI endoscopy. The Clinical Affairs Committee of the Canadian Association of Gastroenterology (CAG) conducted systematic reviews and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations for the use of Buscopan during GI endoscopy. To summarize, we recommend against the use of Buscopan before or during colonoscopy (strong recommendation, high certainty of evidence). We suggest against the use of Buscopan before or during gastroscopy (conditional recommendation, very low certainty of evidence). We suggest the use of Buscopan before or during ERCP (conditional recommendation, very low certainty of evidence). More research is needed to determine whether patients undergoing advanced procedures such as endoscopic mucosal resection or endoscopic submucosal dissection benefit from its use. Buscopan should be used with caution in patients with cardiac comorbidities. According to its product monograph, Buscopan is contraindicated in patients with tachycardia, angina, and cardiac failure. Thus, Buscopan should be used very cautiously in patients with these conditions, and only when the potential benefits of its use outweigh the potential risks in a particular case. Such patients require careful cardiac monitoring in an environment where resuscitation equipment and appropriately trained staff to use it are readily available. According to its product monograph, Buscopan is also contraindicated in patients with prostatic hypertrophy with urinary retention, and therefore, should be used very cautiously in such patients as well, and only when the potential benefits of its use outweigh the potential risks in a particular case. Obtaining a preprocedural history of glaucoma is unlikely to be of value when considering Buscopan use. However, in cases where Buscopan has been used, patients should be counselled postprocedurally and told to present to an emergency facility should they experience eye pain, redness, decreased vision, nausea and vomiting or headache.
Collapse
Affiliation(s)
- Nauzer Forbes
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Levi Frehlich
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Mark Borgaonkar
- Faculty of Medicine, Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada.,Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Frances Tse
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada.,Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
7
|
Balart MT, Russell L, Narula N, Bajaj G, Chauhan U, Khan KJ, Marwaha AN, Ching E, Biro J, Halder S, Tse F, Marshall JK, Collins SM, Moayyedi P, Bercik P, Verdu EF, Leontiadis GI, Armstrong D, Pinto-Sanchez MI. Declining Use of Corticosteroids for Crohn's Disease Has Implications for Study Recruitment: Results of a Pilot Randomized Controlled Trial. J Can Assoc Gastroenterol 2021; 4:214-221. [PMID: 34617003 PMCID: PMC8489529 DOI: 10.1093/jcag/gwaa037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 10/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background Corticosteroids (CS) have been used extensively to induce remission in Crohn’s disease (CD); however, they are associated with severe side effects. We hypothesized that the administration of an exclusive enteral nutrition (EEN) formula to CS would lead to increased CD remission rates and to decreased CS-related adverse events. We proposed to undertake a pilot study comparing EEN and CS therapy to CS alone to assess decrease symptoms and inflammatory markers over 6 weeks. Aim The overall aim was to assess study feasibility based on recruitment rates and acceptability of treatment in arms involving EEN Methods The pilot study intended to recruit 100 adult patients with active CD who had been prescribed CS to induce remission as part of their care. The patients were randomized to one of three arms: (i) standard-dose CS; (ii) standard-dose CS plus EEN (Modulen 1.5 kcal); or (iii) short-course CS plus EEN. Results A total of 2009 CD patients attending gastroenterology clinics were screened from October 2018 to November 2019. Prednisone was prescribed to only 6.8% (27/399) of patients with active CD attending outpatient clinics. Of the remaining 372 patients with active CD, 34.8% (139/399) started or escalated immunosuppressant or biologics, 49.6% (198/399) underwent further investigation and 8.8% (35/399) were offered an alternative treatment (e.g., antibiotics, surgery or investigational agents in clinical trials). Only three patients were enrolled in the study (recruitment rate 11%; 3/27), and the study was terminated for poor recruitment. Conclusion The apparent decline in use of CS for treatment of CD has implications for CS use as an entry criterion for clinical trials.
Collapse
Affiliation(s)
- M T Balart
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - L Russell
- McMaster University Medical Centre, Hamilton, ON, Canada
| | - N Narula
- McMaster University Medical Centre, Hamilton, ON, Canada
| | - G Bajaj
- McMaster University Medical Centre, Hamilton, ON, Canada.,Brampton Endoscopy Centre, Brampton, ON, Canada
| | - U Chauhan
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada
| | - K J Khan
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada.,St. Joseph's Health Care Centre, Hamilton, ON, Canada
| | | | - E Ching
- GI Health Centre, Burlington, ON, Canada
| | - J Biro
- McMaster University Medical Centre, Hamilton, ON, Canada
| | - S Halder
- McMaster University Medical Centre, Hamilton, ON, Canada
| | - F Tse
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - J K Marshall
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - S M Collins
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - P Moayyedi
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - P Bercik
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - E F Verdu
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - G I Leontiadis
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - D Armstrong
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| | - M I Pinto-Sanchez
- Farncombe Family Digestive Health Research Institute, Hamilton, ON, Canada.,McMaster University Medical Centre, Hamilton, ON, Canada
| |
Collapse
|
8
|
Jones JL, Tse F, Carroll MW, deBruyn JC, McNeil SA, Pham-Huy A, Seow CH, Barrett LL, Bessissow T, Carman N, Melmed GY, Vanderkooi OG, Marshall JK, Benchimol EI. Canadian Association of Gastroenterology Clinical Practice Guideline for Immunizations in Patients With Inflammatory Bowel Disease (IBD)-Part 2: Inactivated Vaccines. J Can Assoc Gastroenterol 2021; 4:e72-e91. [PMID: 34476339 PMCID: PMC8407486 DOI: 10.1093/jcag/gwab016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Indexed: 12/19/2022] Open
Abstract
Background and Aims The effectiveness and safety of vaccinations can be altered by
immunosuppressive therapies, and perhaps by inflammatory bowel disease (IBD)
itself. These recommendations developed by the Canadian Association of
Gastroenterology and endorsed by the American Gastroenterological
Association, aim to provide guidance on immunizations in adult and pediatric
patients with IBD. This publication focused on inactivated vaccines. Methods Systematic reviews evaluating the efficacy, effectiveness, and safety of
vaccines in patients with IBD, other immune-mediated inflammatory diseases,
and the general population were performed. Critical outcomes included
mortality, vaccine-preventable diseases, and serious adverse events.
Immunogenicity was considered a surrogate outcome for vaccine efficacy.
Certainty of evidence and strength of recommendations were rated according
to the GRADE (Grading of Recommendation Assessment, Development, and
Evaluation) approach. Key questions were developed through an iterative
online platform, and voted on by a multidisciplinary group. Recommendations
were formulated using the Evidence-to-Decision framework. Strong
recommendation means that most patients should receive the recommended
course of action, whereas a conditional recommendation means that different
choices will be appropriate for different patients. Results Consensus was reached on 15 of 20 questions. Recommendations address the
following vaccines: Haemophilus influenzae type b,
recombinant zoster, hepatitis B, influenza, pneumococcus, meningococcus,
tetanus-diphtheria-pertussis, and human papillomavirus. Most of the
recommendations for patients with IBD are congruent with the current Centers
for Disease Control and Prevention and Canada’s National Advisory
Committee on Immunization recommendations for the general population, with
the following exceptions. In patients with IBD, the panel suggested
Haemophilus influenzae type b vaccine for patients
older than 5 years of age, recombinant zoster vaccine for adults younger
than 50 year of age, and hepatitis B vaccine for adults without a risk
factor. Consensus was not reached, and recommendations were not made for 5
statements, due largely to lack of evidence, including double-dose hepatitis
B vaccine, timing of influenza immunization in patients on biologics,
pneumococcal and meningococcal vaccines in adult patients without risk
factors, and human papillomavirus vaccine in patients aged 27–45
years. Conclusions Patients with IBD may be at increased risk of some vaccine-preventable
diseases. Therefore, maintaining appropriate vaccination status in these
patients is critical to optimize patient outcomes. In general, IBD is not a
contraindication to the use of inactivated vaccines, but immunosuppressive
therapy may reduce vaccine responses.
Collapse
Affiliation(s)
- Jennifer L Jones
- Department of Medicine and Community Health and Epidemiology, Dalhousie University, Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada
| | - Frances Tse
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Matthew W Carroll
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer C deBruyn
- Section of Pediatric Gastroenterology, Departments of Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Shelly A McNeil
- Division of Infectious Diseases, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Anne Pham-Huy
- Division of Infectious Diseases, Immunology and Allergy, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Cynthia H Seow
- Division of Gastroenterology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Lisa L Barrett
- Division of Infectious Diseases, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Talat Bessissow
- Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Nicholas Carman
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Gil Y Melmed
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Otto G Vanderkooi
- Section of Infectious Diseases, Departments of Pediatrics, Microbiology, Immunology and Infectious Diseases, Pathology and Laboratory Medicine and Community Health Sciences, University of Calgary, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Eric I Benchimol
- Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada, SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children, Child Health Evaluative Sciences, SickKids Research Institute, ICES, Toronto, Ontario, Canada.,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario and CHEO Research Institute, Ottawa, Ontario, Canada.,ICES Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
9
|
Benchimol EI, Tse F, Carroll MW, deBruyn JC, McNeil SA, Pham-Huy A, Seow CH, Barrett LL, Bessissow T, Carman N, Melmed GY, Vanderkooi OG, Marshall JK, Jones JL. Canadian Association of Gastroenterology Clinical Practice Guideline for Immunizations in Patients With Inflammatory Bowel Disease (IBD)-Part 1: Live Vaccines. J Can Assoc Gastroenterol 2021; 4:e59-e71. [PMID: 34476338 PMCID: PMC8407487 DOI: 10.1093/jcag/gwab015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/16/2020] [Indexed: 12/16/2022] Open
Abstract
Background & Aims Patients with inflammatory bowel disease (IBD) may be at increased risk of
some vaccine-preventable diseases. The effectiveness and safety of
vaccinations may be altered by immunosuppressive therapies or IBD itself.
These recommendations, developed by the Canadian Association of
Gastroenterology and endorsed by the American Gastroenterological
Association, aim to provide guidance on immunizations in patients with
inflammatory bowel disease. This publication focused on live vaccines. Methods Systematic reviews evaluating the efficacy, effectiveness, and safety of
vaccines in patients with IBD, other immune-mediated inflammatory diseases,
and the general population were performed. Critical outcomes included
mortality, vaccine-preventable diseases, and serious adverse events.
Immunogenicity was considered a surrogate outcome for vaccine efficacy.
Certainty of evidence and strength of recommendations were rated according
to the GRADE (Grading of Recommendation Assessment, Development, and
Evaluation) approach. Key questions were developed through an iterative
process and voted on by a multidisciplinary panel. Recommendations were
formulated using the Evidence-to-Decision framework. Strong recommendation
means that most patients should receive the recommended course of action,
whereas a conditional recommendation means that different choices will be
appropriate for different patients. Results Three good practice statements included reviewing a patient’s
vaccination status at diagnosis and at regular intervals, giving appropriate
vaccinations as soon as possible, and not delaying urgently needed
immunosuppressive therapy to provide vaccinations. There are 4
recommendations on the use of live vaccines. Measles, mumps, rubella vaccine
is recommended for both adult and pediatric patients with IBD not on
immunosuppressive therapy, but not for those using immunosuppressive
medications (conditional). Varicella vaccine is recommended for pediatric
patients with IBD not on immunosuppressive therapy, but not for those using
immunosuppressive medications (conditional). For adults, recommendations are
conditionally in favor of varicella vaccine for those not on
immunosuppressive therapy, and against for those on therapy. No
recommendation was made regarding the use of live vaccines in infants born
to mothers using biologics because the desirable and undesirable effects
were closely balanced and the evidence was insufficient. Conclusions Maintaining appropriate vaccination status in patients with IBD is critical
to optimize patient outcomes. In general, live vaccines are recommended in
patients not on immunosuppressive therapy, but not for those using
immunosuppressive medications. Additional studies are needed to evaluate the
safety and efficacy of live vaccines in patients on immunosuppressive
therapy.
Collapse
Affiliation(s)
- Eric I Benchimol
- Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, and CHEO Research Institute, Ottawa, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada, SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children, Child Health Evaluative Sciences, SickKids Research Institute, ICES, Toronto, Ontario, Canada
| | - Frances Tse
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Matthew W Carroll
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer C deBruyn
- Section of Pediatric Gastroenterology, Departments of Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Shelly A McNeil
- Division of Infectious Diseases, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Anne Pham-Huy
- Division of Infectious Diseases, Immunology and Allergy, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario
| | - Cynthia H Seow
- Division of Gastroenterology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Lisa L Barrett
- Division of Infectious Diseases, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Talat Bessissow
- Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Nicholas Carman
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Gil Y Melmed
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Otto G Vanderkooi
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California.,Section of Infectious Diseases, Departments of Pediatrics, Microbiology, Immunology and Infectious Diseases, Pathology and Laboratory Medicine and Community Health Sciences, University of Calgary, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jennifer L Jones
- Department of Medicine and Community Health and Epidemiology, Dalhousie University, Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada
| |
Collapse
|
10
|
Tse F, Yuan Y, Moayyedi P, Leontiadis GI. Electrosurgical current for endoscopic biliary sphincterotomy (EBS) for the prevention of post endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Hippokratia 2021. [DOI: 10.1002/14651858.cd009643.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Frances Tse
- Department of Medicine, Division of Gastroenterology; McMaster University; Hamilton Canada
| | - Yuhong Yuan
- Department of Medicine, Division of Gastroenterology; McMaster University; Hamilton Canada
| | - Paul Moayyedi
- Department of Medicine, Division of Gastroenterology; McMaster University; Hamilton Canada
| | - Grigorios I Leontiadis
- Department of Medicine, Division of Gastroenterology; McMaster University; Hamilton Canada
| |
Collapse
|
11
|
Benchimol EI, Tse F, Carroll MW, deBruyn JC, McNeil SA, Pham-Huy A, Seow CH, Barrett LL, Bessissow T, Carman N, Melmed GY, Vanderkooi OG, Marshall JK, Jones JL. Canadian Association of Gastroenterology Clinical Practice Guideline for Immunizations in Patients With Inflammatory Bowel Disease (IBD)-Part 1: Live Vaccines. Gastroenterology 2021; 161:669-680.e0. [PMID: 33617891 DOI: 10.1053/j.gastro.2020.12.079] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/10/2020] [Accepted: 12/16/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel disease (IBD) may be at increased risk of some vaccine-preventable diseases. The effectiveness and safety of vaccinations may be altered by immunosuppressive therapies or IBD itself. These recommendations developed by the Canadian Association of Gastroenterology and endorsed by the American Gastroenterological Association, aim to provide guidance on immunizations in adult and pediatric patients with IBD. This publication focused on live vaccines. METHODS Systematic reviews evaluating the efficacy, effectiveness, and safety of vaccines in patients with IBD, other immune-mediated inflammatory diseases, and the general population were performed. Critical outcomes included mortality, vaccine-preventable diseases, and serious adverse events. Immunogenicity was considered a surrogate outcome for vaccine efficacy. Certainty of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. Key questions were developed through an iterative process and voted on by a multidisciplinary panel. Recommendations were formulated using the Evidence-to-Decision framework. Strong recommendation means that most patients should receive the recommended course of action, whereas a conditional recommendation means that different choices will be appropriate for different patients. RESULTS Three good practice statements included reviewing a patient's vaccination status at diagnosis and at regular intervals, giving appropriate vaccinations as soon as possible, and not delaying urgently needed immunosuppressive therapy to provide vaccinations. There are 4 recommendations on the use of live vaccines. Measles, mumps, rubella vaccine is recommended for both adult and pediatric patients with IBD not on immunosuppressive therapy, but not for those using immunosuppressive medications (conditional). Varicella vaccine is recommended for pediatric patients with IBD not on immunosuppressive therapy, but not for those using immunosuppressive medications (conditional). For adults, recommendations are conditionally in favor of varicella vaccine for those not on immunosuppressive therapy, and against for those on therapy. No recommendation was made regarding the use of live vaccines in infants born to mothers using biologics because the desirable and undesirable effects were closely balanced and the evidence was insufficient. CONCLUSIONS Maintaining appropriate vaccination status in patients with IBD is critical to optimize patient outcomes. In general, live vaccines are recommended in patients not on immunosuppressive therapy, but not for those using immunosuppressive medications. Additional studies are needed to evaluate the safety and efficacy of live vaccines in patients on immunosuppressive therapy.
Collapse
Affiliation(s)
- Eric I Benchimol
- Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada, CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, and CHEO Research Institute, Ottawa, Ontario, Canada; Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada, SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children, Child Health Evaluative Sciences, SickKids Research Institute, ICES, Toronto, Ontario, Canada
| | - Frances Tse
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Matthew W Carroll
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer C deBruyn
- Section of Pediatric Gastroenterology, Departments of Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Shelly A McNeil
- Division of Infectious Diseases, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Anne Pham-Huy
- Division of Infectious Diseases, Immunology and Allergy, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario
| | - Cynthia H Seow
- Division of Gastroenterology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Lisa L Barrett
- Division of Infectious Diseases, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Talat Bessissow
- Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Nicholas Carman
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada, CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Gil Y Melmed
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Otto G Vanderkooi
- Section of Infectious Diseases, Departments of Pediatrics, Microbiology, Immunology and Infectious Diseases, Pathology and Laboratory Medicine and Community Health Sciences, University of Calgary, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jennifer L Jones
- Department of Medicine and Community Health and Epidemiology, Dalhousie University, Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada
| |
Collapse
|
12
|
Jones JL, Tse F, Carroll MW, deBruyn JC, McNeil SA, Pham-Huy A, Seow CH, Barrett LL, Bessissow T, Carman N, Melmed GY, Vanderkooi OG, Marshall JK, Benchimol EI. Canadian Association of Gastroenterology Clinical Practice Guideline for Immunizations in Patients With Inflammatory Bowel Disease (IBD)-Part 2: Inactivated Vaccines. Gastroenterology 2021; 161:681-700. [PMID: 34334167 DOI: 10.1053/j.gastro.2021.04.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The effectiveness and safety of vaccinations can be altered by immunosuppressive therapies, and perhaps by inflammatory bowel disease (IBD) itself. These recommendations developed by the Canadian Association of Gastroenterology and endorsed by the American Gastroenterological Association, aim to provide guidance on immunizations in adult and pediatric patients with IBD. This publication focused on inactivated vaccines. METHODS Systematic reviews evaluating the efficacy, effectiveness, and safety of vaccines in patients with IBD, other immune-mediated inflammatory diseases, and the general population were performed. Critical outcomes included mortality, vaccine-preventable diseases, and serious adverse events. Immunogenicity was considered a surrogate outcome for vaccine efficacy. Certainty of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. Key questions were developed through an iterative online platform, and voted on by a multidisciplinary group. Recommendations were formulated using the Evidence-to-Decision framework. Strong recommendation means that most patients should receive the recommended course of action, whereas a conditional recommendation means that different choices will be appropriate for different patients. RESULTS Consensus was reached on 15 of 20 questions. Recommendations address the following vaccines: Haemophilus influenzae type b, recombinant zoster, hepatitis B, influenza, pneumococcus, meningococcus, tetanus-diphtheria-pertussis, and human papillomavirus. Most of the recommendations for patients with IBD are congruent with the current Centers for Disease Control and Prevention and Canada's National Advisory Committee on Immunization recommendations for the general population, with the following exceptions. In patients with IBD, the panel suggested Haemophilus influenzae type b vaccine for patients older than 5 years of age, recombinant zoster vaccine for adults younger than 50 year of age, and hepatitis B vaccine for adults without a risk factor. Consensus was not reached, and recommendations were not made for 5 statements, due largely to lack of evidence, including double-dose hepatitis B vaccine, timing of influenza immunization in patients on biologics, pneumococcal and meningococcal vaccines in adult patients without risk factors, and human papillomavirus vaccine in patients aged 27-45 years. CONCLUSIONS Patients with IBD may be at increased risk of some vaccine-preventable diseases. Therefore, maintaining appropriate vaccination status in these patients is critical to optimize patient outcomes. In general, IBD is not a contraindication to the use of inactivated vaccines, but immunosuppressive therapy may reduce vaccine responses.
Collapse
Affiliation(s)
- Jennifer L Jones
- Department of Medicine and Community Health and Epidemiology, Dalhousie University, Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada.
| | - Frances Tse
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Matthew W Carroll
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer C deBruyn
- Section of Pediatric Gastroenterology, Departments of Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Shelly A McNeil
- Division of Infectious Diseases, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Anne Pham-Huy
- Division of Infectious Diseases, Immunology and Allergy, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Cynthia H Seow
- Division of Gastroenterology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Lisa L Barrett
- Division of Infectious Diseases, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Talat Bessissow
- Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Nicholas Carman
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada, CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Gil Y Melmed
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Otto G Vanderkooi
- Section of Infectious Diseases, Departments of Pediatrics, Microbiology, Immunology and Infectious Diseases, Pathology and Laboratory Medicine and Community Health Sciences, University of Calgary, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Eric I Benchimol
- Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada, CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario and CHEO Research Institute, Ottawa, Ontario, Canada, ICES Ottawa, Ottawa, Ontario, Canada; Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada, SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology Hepatology and Nutrition, The Hospital for Sick Children, Child Health Evaluative Sciences, SickKids Research Institute, ICES, Toronto, Ontario, Canada.
| |
Collapse
|
13
|
Farbod Y, Popov J, Armstrong D, Halder S, Marshall JK, Tse F, Pinto-Sanchez MI, Moayyedi P, Chauhan U. Reduction in Anxiety and Depression Scores Associated with Improvement in Quality of Life in Patients with Inflammatory Bowel Disease. J Can Assoc Gastroenterol 2021; 5:12-17. [DOI: 10.1093/jcag/gwab008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 04/08/2021] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The aim of this study was to examine the associations among depression, anxiety and health-related quality of life and predictors of improvement of quality of life in patients with inflammatory bowel disease.
Methods
This was a prospective cohort study conducted in the gastroenterology clinic at McMaster University Medical Center in Hamilton, Ontario, Canada from May 2014 to March 2015. We included 60 adult patients above the age of 18 years old with a diagnosis of inflammatory bowel disease. We assessed anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) and Health Related Quality of Life (HRQoL) using the Short Inflammatory Bowel Disease questionnaire (SIBDQ) at baseline and after 6 months. Linear regression was performed to estimate the associations among depression, anxiety and predictors of improvement in health-related quality of life.
Results
The anxiety scores decreased over the span of 6 months (median HADS-A baseline 9.00 [interquartile range {IQR} 6 to 12], and median HADS-A 6 months 7.00 [IQR 3.75 to 7.00]). There was a moderate negative correlation between anxiety (baseline r = −0.510, and 6-month r = −0.620; P < 0.001), depression (baseline r = −0.630, and 6-month r = −0.670; P < 0.001) and HRQoL scores. Using a multivariate linear regression model, elevated HADS score were associated with lower SIBDQ scores at baseline (Beta coefficient −0.696 [95% confidence interval {CI} −1.51 to −0.842]; P < 0.001). Lower SIBDQ score at baseline predicted decreased SIBDQ at 6 months (Beta coefficient 0.712 [95% CI 0.486 to 1.02]; P < 0.001).
Conclusion
Anxiety and depression are frequently seen in inflammatory bowel disease patients and lead to poor HRQoL. Psychological comorbidities may contribute to maladaptive behaviours and difficult disease management.
Collapse
Affiliation(s)
- Yasamin Farbod
- Poznan University of Medical Sciences, Medicine, Poznan, Poland
- Hamilton Health Sciences, Adult Digestive Diseases, Hamilton, Ontario, Canada
| | - Jelena Popov
- Hamilton Health Sciences, Adult Digestive Diseases, Hamilton, Ontario, Canada
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - David Armstrong
- Department of Medicine, Division of Gastroenterology, and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Smita Halder
- Department of Medicine, Division of Gastroenterology, and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - John K Marshall
- Department of Medicine, Division of Gastroenterology, and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Frances Tse
- Department of Medicine, Division of Gastroenterology, and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Maria Ines Pinto-Sanchez
- Department of Medicine, Division of Gastroenterology, and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Paul Moayyedi
- Department of Medicine, Division of Gastroenterology, and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Usha Chauhan
- Hamilton Health Sciences, Adult Digestive Diseases, Hamilton, Ontario, Canada
| |
Collapse
|
14
|
Tse F, Moayyedi P, Waschke KA, MacMillan M, Forbes N, Carroll MW, Carman N, Leontiadis GI. COVID-19 Vaccination in Patients With Inflammatory Bowel Disease: Communiqué From the Canadian Association of Gastroenterology. J Can Assoc Gastroenterol 2021; 4:49. [PMID: 33644678 PMCID: PMC7898369 DOI: 10.1093/jcag/gwaa046] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/04/2021] [Indexed: 01/26/2023] Open
Affiliation(s)
- Frances Tse
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
- Clinical Affairs Committee, Canadian Association of Gastroenterology
| | - Paul Moayyedi
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
- President Elect, Canadian Association of Gastroenterology
| | - Kevin A Waschke
- President, Canadian Association of Gastroenterology
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Mark MacMillan
- Clinical Affairs Committee, Canadian Association of Gastroenterology
- Gastroenterology, Dr. Everett Chalmers Regional Hospital, Dalhousie University, Memorial University, St. John’s, Newfoundland and Labrador, Canada
| | - Nauzer Forbes
- Clinical Affairs Committee, Canadian Association of Gastroenterology
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Matthew W Carroll
- Clinical Affairs Committee, Canadian Association of Gastroenterology
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Nicholas Carman
- Clinical Affairs Committee, Canadian Association of Gastroenterology
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
- Clinical Affairs Committee, Canadian Association of Gastroenterology
| |
Collapse
|
15
|
Rai M, Cooper M, Shulman S, Kottachchi D, Nelles S, Macmillan M, Heitman S, Barkun A, Tse F, Hookey L. Canadian Association of Gastroenterology Communique: After-Hours Endoscopy Cart. J Can Assoc Gastroenterol 2020; 3:222-227. [PMID: 32905048 PMCID: PMC7465551 DOI: 10.1093/jcag/gwz032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/09/2019] [Indexed: 11/19/2022] Open
Abstract
Background Endoscopic procedures performed after-hours often require therapeutic interventions that are technically demanding for the endoscopist. The aim of this position paper is to provide guidance on the minimum standard of equipment that should be available on a mobile endoscopy cart for provision of a safe and effective after-hours emergency endoscopy service. The guidance is based on consensus among academic and community gastroenterologists in Canada. Methods A modified Delphi process was used to establish consensus among 9 participants. A list of statements was prepared by an expert panel of endoscopists. The statements were divided into three broad sections for what should be on an after-hours endoscopy cart including medications, nonendoscopic tools and therapeutic/diagnostic equipment. Consensus for being on the endoscopy cart was achieved when 75% or more of voting members indicated ‘agree’. Results For nonendoscopic tools, there was agreement for having sterile saline, sterile water, endoscope lubricant, various syringes, bite blocks (paediatric and adult size), a water pump with foot peddle, formalin jars for biopsy specimens, digital photo and printing capability and an overtube. For medications, there was agreement for having hyoscine butylbromide and epinephrine on the cart. For therapeutic/diagnostic tools, there was agreement for having biopsy forceps (standard and jumbo), polypectomy snares, sclerotherapy needles and agent (for a variceal bleed), band ligation kit, multipolar electrocautery probes, heater probe catheter, endoscopic clips, hemostatic powder and retrieval devices. Interpretation This position paper provides guidance on the minimum standard of items that should be on an after-hours endoscopy cart. Standardization of equipment may help improve safety and quality of after-hours endoscopic procedures.
Collapse
Affiliation(s)
- Mandip Rai
- Division of Gastroenterology, Queen's University, Kingston, Ontario, Canada
| | - Mary Cooper
- Division of Gastroenterology, North Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Scott Shulman
- Division of Gastroenterology, North Bay Regional Health Centre, North Bay, Ontario, Canada
| | - Dan Kottachchi
- Division of Gastroenterology, Guelph General Hospital, Guelph, Ontario, Canada
| | - Sandra Nelles
- Division of Gastroenterology, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Mark Macmillan
- Division of Gastroenterology, Dalhousie University, Memorial University, Fredericton, New Brunswick, Canada
| | - Steven Heitman
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University and the McGill University Health Centre, Montreal, Quebec, Canada
| | - Frances Tse
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Hookey
- Gastrointestinal Diseases Research Unit, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
16
|
Sengupta NK, Azizov A, Halder S, Xenodemetropoulos T, Armstrong D, Tse F, Marshall JK, Narula N. Higher vedolizumab serum levels do not increase the risk of adverse events in patients with inflammatory bowel disease. Scand J Gastroenterol 2020; 55:800-805. [PMID: 32574083 DOI: 10.1080/00365521.2020.1780470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: Although its mechanism of action may confer a safety benefit, vedolizumab has still been associated with adverse events (AE). We investigated whether inflammatory bowel disease (IBD) patients with higher trough vedolizumab serum levels experienced an increased risk of AEs.Methods: This was a retrospective study of 76 IBD patients with at least one measurement of serum vedolizumab available. Vedolizumab levels ranged from <3.5 mcg/mL to 87.2 mcg/mL (median = 15.8 mcg/mL). The primary outcome was the rate of overall AEs. Secondary outcomes included the rates of infections, dermatologic reactions, infusion reactions, and other AEs. Multivariate logistic regression analysis was performed to evaluate the relationship between serum vedolizumab levels and AEs.Results: 19 patients out of 76 reported AEs. In patients with higher vedolizumab levels, there were 10 AEs reported out of 38 patients, which was not significantly different from the 9 AEs reported in 38 patients with lower vedolizumab levels (26.3% vs. 23.7%, p = .79). After adjustment for potential covariates, IBD patients with higher vedolizumab levels did not have higher odds of an AE than patients with lower levels (OR 0.92, 95% CI 0.30-2.81). Longer duration of therapy had higher odds of AEs, (OR of 1.04 at 95% CI 1.00-1.09, p = .0494 per additional month). None of the other variables were associated with a greater risk of AEs.Conclusions: There does not appear to be an increased risk of adverse events in IBD patients with higher vedolizumab levels, but duration of therapy may increase the risk of AEs.
Collapse
Affiliation(s)
- Neil K Sengupta
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Ahmad Azizov
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Smita Halder
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| | - Ted Xenodemetropoulos
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| | - David Armstrong
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| | - Frances Tse
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| | - John K Marshall
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| | - Neeraj Narula
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| |
Collapse
|
17
|
Ménard C, Waschke K, Tse F, Borgaonkar M, Forbes N, Barkun A, Martel M. COVID-19: Framework for the Resumption of Endoscopic Activities From the Canadian Association of Gastroenterology. J Can Assoc Gastroenterol 2020; 3:243-245. [PMID: 32885139 PMCID: PMC7337808 DOI: 10.1093/jcag/gwaa016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Charles Ménard
- Division of Gastroenterology, University of Sherbrooke, Sherbrooke, Québec, Canada
| | - Kevin Waschke
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Frances Tse
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Mark Borgaonkar
- Faculty of Medicine, Memorial University, St John's, Newfoundland, Canada
| | - Nauzer Forbes
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| |
Collapse
|
18
|
Tse F, Borgaonkar M, Leontiadis GI. COVID-19: Advice from the Canadian Association of Gastroenterology for Endoscopy Facilities, as of March 16, 2020. J Can Assoc Gastroenterol 2020; 3:147-149. [PMID: 32395690 PMCID: PMC7184362 DOI: 10.1093/jcag/gwaa012] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 03/25/2020] [Indexed: 12/13/2022] Open
Affiliation(s)
- Frances Tse
- Practice Affairs Chair, Canadian Association of Gastroenterology, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mark Borgaonkar
- Practice Affairs Chair, Canadian Association of Gastroenterology, Ontario, Canada
- Endoscopy Chair, Canadian Association of Gastroenterology, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, Memorial University, St. John’s, Newfoundland and Labrador, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- VP Clinical Affairs, Canadian Association of Gastroenterology, Ontario, Canada
| |
Collapse
|
19
|
Nie Z, Yeh SCA, LePalud M, Badr F, Tse F, Armstrong D, Liu LWC, Deen MJ, Fang Q. Optical Biopsy of the Upper GI Tract Using Fluorescence Lifetime and Spectra. Front Physiol 2020; 11:339. [PMID: 32477151 PMCID: PMC7237753 DOI: 10.3389/fphys.2020.00339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 03/24/2020] [Indexed: 12/11/2022] Open
Abstract
Screening and surveillance for gastrointestinal (GI) cancers by endoscope guided biopsy is invasive, time consuming, and has the potential for sampling error. Tissue endogenous fluorescence spectra contain biochemical and physiological information, which may enable real-time, objective diagnosis. We first briefly reviewed optical biopsy modalities for GI cancer diagnosis with a focus on fluorescence-based techniques. In an ex vivo pilot clinical study, we measured fluorescence spectra and lifetime on fresh biopsy specimens obtained during routine upper GI screening procedures. Our results demonstrated the feasibility of rapid acquisition of time-resolved fluorescence (TRF) spectra from fresh GI mucosal specimens. We also identified spectroscopic signatures that can differentiate between normal mucosal samples obtained from the esophagus, stomach, and duodenum.
Collapse
Affiliation(s)
- Zhaojun Nie
- School of Biomedical Engineering, Faculty of Engineering, McMaster University, Hamilton, ON, Canada
| | - Shu-Chi Allison Yeh
- Advanced Microscopy Program, Center for Systems Biology and Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Michelle LePalud
- School of Biomedical Engineering, Faculty of Engineering, McMaster University, Hamilton, ON, Canada
| | - Fares Badr
- School of Biomedical Engineering, Faculty of Engineering, McMaster University, Hamilton, ON, Canada
| | - Frances Tse
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - David Armstrong
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Louis W. C. Liu
- Division of Gastrointestinal Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - M. Jamal Deen
- School of Biomedical Engineering, Faculty of Engineering, McMaster University, Hamilton, ON, Canada
- Department of Electrical and Computer Engineering, Faculty of Engineering, McMaster University, Hamilton, ON, Canada
| | - Qiyin Fang
- School of Biomedical Engineering, Faculty of Engineering, McMaster University, Hamilton, ON, Canada
- Department of Engineering Physics, Faculty of Engineering, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
20
|
Pittayanon R, Lau JT, Leontiadis GI, Tse F, Yuan Y, Surette M, Moayyedi P. Differences in Gut Microbiota in Patients With vs Without Inflammatory Bowel Diseases: A Systematic Review. Gastroenterology 2020; 158:930-946.e1. [PMID: 31812509 DOI: 10.1053/j.gastro.2019.11.294] [Citation(s) in RCA: 286] [Impact Index Per Article: 71.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/05/2019] [Accepted: 11/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Altering the intestinal microbiota has been proposed as a treatment for inflammatory bowel diseases (IBDs), but there are no established associations between specific microbes and IBD. We performed a systematic review to identify frequent associations. METHODS We searched the MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials databases, through April 2, 2018 for studies that compared intestinal microbiota (from fecal or colonic or ileal tissue samples) among patients (adult or pediatric) with IBD vs healthy individuals (controls). The primary outcome was difference in specific taxa in fecal or intestinal tissue samples from patients with IBD vs controls. We used the Newcastle-Ottawa scale to assess the quality of studies included in the review. RESULTS We identified 2631 citations; 48 studies from 45 articles were included in the analysis. Most studies evaluated adults with Crohn's disease or ulcerative colitis. All 3 studies of Christensenellaceae and Coriobacteriaceae and 6 of 11 studies of Faecalibacterium prausnitzii reported a decreased amount of those organisms compared with controls, whereas 2 studies each of Actinomyces, Veillonella, and Escherichia coli revealed an increased amount in patients with Crohn's disease. For patients with ulcerative colitis, Eubacterium rectale and Akkermansia were decreased in all 3 studies, whereas E coli was increased in 4 of 9 studies. The microbiota diversity was either decreased or not different in patients with IBD vs controls. Fewer than 50% of the studies stated comparable sexes and ages of cases and controls. CONCLUSIONS In a systematic review, we found evidence for differences in abundances of some bacteria in patients with IBD vs controls, but we cannot make conclusions due to inconsistent results and methods among studies. Further large-scale studies, with better methods of assessing microbe populations, are needed.
Collapse
Affiliation(s)
- Rapat Pittayanon
- Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Jennifer T Lau
- Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Grigorios I Leontiadis
- Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Frances Tse
- Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Yuhong Yuan
- Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Michael Surette
- Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Paul Moayyedi
- Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
21
|
Sadowski DC, Camilleri M, Chey WD, Leontiadis GI, Marshall JK, Shaffer EA, Tse F, Walters JRF. Canadian Association of Gastroenterology Clinical Practice Guideline on the Management of Bile Acid Diarrhea. Clin Gastroenterol Hepatol 2020; 18:24-41.e1. [PMID: 31526844 DOI: 10.1016/j.cgh.2019.08.062] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 08/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Chronic diarrhea affects about 5% of the population overall. Altered bile acid metabolism is a common but frequently undiagnosed cause. METHODS We performed a systematic search of publication databases for studies of assessment and management of bile acid diarrhea (BAD). The certainty (quality) of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation approach. Patient population, intervention, comparator, and outcome questions were developed through an iterative process and were voted on by a group of specialists. RESULTS The certainty of evidence was generally rated as very low. Therefore, 16 of 17 recommendations are conditional. In patients with chronic diarrhea, consideration of risk factors (terminal ileal resection, cholecystectomy, or abdominal radiotherapy), but not additional symptoms, was recommended for identification of patients with possible BAD. The group suggested testing using 75selenium homocholic acid taurine (where available) or 7α-hydroxy-4-cholesten-3-one, including patients with irritable bowel syndrome with diarrhea, functional diarrhea, and Crohn's disease without inflammation. Testing was suggested over empiric bile acid sequestrant therapy (BAST). Once remediable causes are managed, the group suggested cholestyramine as initial therapy, with alternate BAST when tolerability is an issue. The group suggested against BAST for patients with extensive ileal Crohn's disease or resection and suggested alternative antidiarrheal agents if BAST is not tolerated. Maintenance BAST should be given at the lowest effective dose, with a trial of intermittent, on-demand administration, concurrent medication review, and reinvestigation for patients whose symptoms persist despite BAST. CONCLUSIONS Based on a systematic review, BAD should be considered for patients with chronic diarrhea. For patients with positive results from tests for BAD, a trial of BAST, initially with cholestyramine, is suggested.
Collapse
Affiliation(s)
- Daniel C Sadowski
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada.
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - William D Chey
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan
| | - Grigorios I Leontiadis
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Eldon A Shaffer
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Frances Tse
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Julian R F Walters
- Division of Digestive Diseases, Imperial College London, London, United Kingdom
| |
Collapse
|
22
|
Sadowski DC, Camilleri M, Chey WD, Leontiadis GI, Marshall JK, Shaffer EA, Tse F, Walters JRF. Canadian Association of Gastroenterology Clinical Practice Guideline on the Management of Bile Acid Diarrhea. J Can Assoc Gastroenterol 2019; 3:e10-e27. [PMID: 32010878 PMCID: PMC6985689 DOI: 10.1093/jcag/gwz038] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background and Aims Chronic diarrhea affects about 5% of the population overall. Altered bile acid metabolism is a common but frequently undiagnosed cause. Methods We performed a systematic search of publication databases for studies of assessment and management of bile acid diarrhea (BAD). The certainty (quality) of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation approach. Patient population, intervention, comparator and outcome questions were developed through an iterative process and were voted on by a group of specialists. Results The certainty of evidence was generally rated as very low. Therefore, 16 of 17 recommendations are conditional. In patients with chronic diarrhea, consideration of risk factors (terminal ileal resection, cholecystectomy or abdominal radiotherapy), but not additional symptoms, was recommended for identification of patients with possible BAD. The group suggested testing using 75selenium homocholic acid taurine (where available) or 7α-hydroxy-4-cholesten-3-one, including patients with irritable bowel syndrome with diarrhea, functional diarrhea and Crohn's disease without inflammation. Testing was suggested over empiric bile acid sequestrant therapy (BAST). Once remediable causes are managed, the group suggested cholestyramine as initial therapy, with alternate BAST when tolerability is an issue. The group suggested against BAST for patients with extensive ileal Crohn's disease or resection and suggested alternative antidiarrheal agents if BAST is not tolerated. Maintenance BAST should be given at the lowest effective dose, with a trial of intermittent, on-demand administration, concurrent medication review and reinvestigation for patients whose symptoms persist despite BAST. Conclusions Based on a systematic review, BAD should be considered for patients with chronic diarrhea. For patients with positive results from tests for BAD, a trial of BAST, initially with cholestyramine, is suggested.
Collapse
Affiliation(s)
- Daniel C Sadowski
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - William D Chey
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Grigorios I Leontiadis
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Eldon A Shaffer
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Frances Tse
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | | |
Collapse
|
23
|
Barkun AN, Almadi M, Kuipers EJ, Laine L, Sung J, Tse F, Leontiadis GI, Abraham NS, Calvet X, Chan FKL, Douketis J, Enns R, Gralnek IM, Jairath V, Jensen D, Lau J, Lip GYH, Loffroy R, Maluf-Filho F, Meltzer AC, Reddy N, Saltzman JR, Marshall JK, Bardou M. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med 2019; 171:805-822. [PMID: 31634917 PMCID: PMC7233308 DOI: 10.7326/m19-1795] [Citation(s) in RCA: 259] [Impact Index Per Article: 51.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
DESCRIPTION This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and presents new clinically relevant recommendations. METHODS An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional. RECOMMENDATIONS Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.
Collapse
Affiliation(s)
- Alan N Barkun
- McGill University, Montreal, Quebec, Canada (A.N.B.)
| | - Majid Almadi
- McGill University, Montreal, Quebec, Canada, and King Saud University, Riyadh, Saudi Arabia (M.A.)
| | - Ernst J Kuipers
- Erasmus University Medical Center, Rotterdam, the Netherlands (E.J.K.)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, and VA Connecticut Healthcare System, West Haven, Connecticut (L.L.)
| | - Joseph Sung
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - Frances Tse
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | | | | | - Xavier Calvet
- Hospital Parc Taulí de Sabadell, University of Barcelona, Sabadell, Spain, and CiberEHD (Instituto de Salud Carlos III), Madrid, Spain (X.C.)
| | - Francis K L Chan
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - James Douketis
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | - Robert Enns
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada (R.E.)
| | - Ian M Gralnek
- Technion-Israel Institute of Technology, Emek Medical Center, Afula, Israel (I.M.G.)
| | | | - Dennis Jensen
- University of California, Los Angeles, Los Angeles, California (D.J.)
| | - James Lau
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - Gregory Y H Lip
- University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom, and Aalborg University, Aalborg, Denmark (G.Y.L.)
| | - Romaric Loffroy
- Dijon-Bourgogne University Hospital, Dijon, France (R.L., M.B.)
| | | | | | - Nageshwar Reddy
- Asian Institute of Gastroenterology, Hyderabad, India (N.R.)
| | - John R Saltzman
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (J.R.S.)
| | - John K Marshall
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | - Marc Bardou
- Dijon-Bourgogne University Hospital, Dijon, France (R.L., M.B.)
| |
Collapse
|
24
|
Wilkinson AN, Lieberman D, Leontiadis GI, Tse F, Barkun AN, Abou-Setta A, Marshall JK, Samadder J, Singh H, Telford JJ, Tinmouth J, Leddin D. Colorectal cancer screening for patients with a family history of colorectal cancer or adenomas. Can Fam Physician 2019; 65:784-789. [PMID: 31722908 PMCID: PMC6853346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To review and summarize the recently developed Canadian Association of Gastroenterology screening recommendations for patients with a family history of colorectal cancer (CRC) or adenoma from a family medicine perspective. QUALITY OF EVIDENCE A systematic review and meta-analysis was performed to synthesize knowledge regarding family history and CRC. The Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE were searched with the following MeSH terms: colorectal cancers or neoplasms, screen or screening or surveillance, and family or family history. Known hereditary syndromes were excluded. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to establish certainty in reviewed evidence. Most recommendations are conditional recommendations with very low-quality evidence. MAIN MESSAGE Individuals who have 1 first-degree relative (FDR) with CRC or an advanced adenoma diagnosed at any age are recommended to undergo colonoscopy every 5 to 10 years starting at age 40 to 50 years or 10 years younger than the age at diagnosis of the FDR, although fecal immunochemical testing at an interval of every 1 to 2 years can be used. Individuals with FDRs with non-advanced adenomas or a history of CRC in second-degree relatives should be screened according to average-risk guidelines. Lifestyle modification can statistically significantly decrease risk of CRC and should be considered in all patients. CONCLUSION These guidelines acknowledge the many factors that can increase an individual's risk of developing CRC and allow for judgment to be employed depending on the clinical scenario. Lifestyle advice already given to patients for weight, blood pressure, and heart disease management will reduce the risk of CRC if implemented, and this combined with more targeted screening for higher-risk individuals will hopefully be successful in decreasing CRC mortality in Canada.
Collapse
Affiliation(s)
- Anna N Wilkinson
- Assistant Professor in the Department of Family Medicine and the Department of Oncology and Program Director of the third-year family physician oncology program at the University of Ottawa in Ontario.
| | - David Lieberman
- Professor of Medicine and Chief of the Division of Gastroenterology and Hepatology at Oregon Health and Science University in Portland
| | - Grigorios I Leontiadis
- Associate Professor in the Division of Gastroenterology at McMaster University Health Sciences Centre in Hamilton, Ont
| | - Frances Tse
- Associate Professor and Chief of Service, Gastroenterology, in the Division of Gastroenterology at McMaster University
| | - Alan N Barkun
- Chairholder of the Douglas G. Kinnear Chair in Gastroenterology and Professor of Medicine, Director of the Endoscopy and Therapeutic Endoscopy Training Program, and Chief Quality Officer in the Division of Gastroenterology at McGill University and the McGill University Health Centre in Montreal, Que
| | - Ahmed Abou-Setta
- Director of the Knowledge Synthesis platform at the George and Fay Yee Centre for Healthcare Innovation at the University of Manitoba in Winnipeg
| | - John K Marshall
- Professor of Medicine and Director of the Division of Gastroenterology at McMaster University
| | - Jewel Samadder
- Associate Professor and Director of the High Risk Cancer Clinic in the Division of Gastroenterology and Hepatology at the Mayo Clinic in Phoenix, Ariz
| | - Harminder Singh
- Associate Professor in the Department of Internal Medicine and the Department of Community Health Sciences at the University of Manitoba and in the Department of Hematology and Oncology of CancerCare Manitoba
| | - Jennifer J Telford
- Clinical Professor of Medicine at the University of British Columbia in Vancouver and Medical Director of the BC Colon Screening Program at Pacific Gastroenterology Associates
| | - Jill Tinmouth
- Assistant Professor in the Department of Medicine at the University of Toronto in Ontario, Scientist in Evaluative Clinical Sciences in the Odette Cancer Research Program at the Sunnybrook Research Institute, a staff physician at Sunnybrook Health Sciences Centre, Adjunct Scientist at ICES, a faculty member of the Institute of Health Policy, Management and Evaluation at the University of Toronto, and Lead Scientist of the ColonCancerCheck program at Cancer Care Ontario
| | - Desmond Leddin
- Adjunct Professor of Medicine at the University of Limerick in Ireland and at Dalhousie University in Halifax, NS, and Head of Graduate Entry Medical School at the University of Limerick
| |
Collapse
|
25
|
Mack DR, Benchimol EI, Critch J, deBruyn J, Tse F, Moayyedi P, Church P, Deslandres C, El-Matary W, Huynh H, Jantchou P, Lawrence S, Otley A, Sherlock M, Walters T, Kappelman MD, Sadowski D, Marshall JK, Griffiths A. Canadian Association of Gastroenterology Clinical Practice Guideline for the Medical Management of Pediatric Luminal Crohn's Disease. Gastroenterology 2019; 157:320-348. [PMID: 31320109 DOI: 10.1053/j.gastro.2019.03.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/28/2019] [Accepted: 03/02/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS We aim to provide guidance for medical treatment of luminal Crohn's disease in children. METHODS We performed a systematic search of publication databases to identify studies of medical management of pediatric Crohn's disease. Quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. We developed statements through an iterative online platform and then finalized and voted on them. RESULTS The consensus includes 25 statements focused on medical treatment options. Consensus was not reached, and no recommendations were made, for 14 additional statements, largely due to lack of evidence. The group suggested corticosteroid therapies (including budesonide for mild to moderate disease). The group suggested exclusive enteral nutrition for induction therapy and biologic tumor necrosis factor antagonists for induction and maintenance therapy at diagnosis or at early stages of severe disease, and for patients failed by steroid and immunosuppressant induction therapies. The group recommended against the use of oral 5-aminosalicylate for induction or maintenance therapy in patients with moderate disease, and recommended against thiopurines for induction therapy, corticosteroids for maintenance therapy, and cannabis in any role. The group was unable to clearly define the role of concomitant immunosuppressants during initiation therapy with a biologic agent, although thiopurine combinations are not recommended for male patients. No consensus was reached on the role of aminosalicylates in treatment of patients with mild disease, antibiotics or vedolizumab for induction or maintenance therapy, or methotrexate for induction therapy. Patients in clinical remission who are receiving immunomodulators should be assessed for mucosal healing within 1 year of treatment initiation. CONCLUSIONS Evidence-based medical treatment of Crohn's disease in children is recommended, with thorough ongoing assessments to define treatment success.
Collapse
Affiliation(s)
- David R Mack
- Children's Hospital of Eastern Ontario Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada; Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
| | - Eric I Benchimol
- Children's Hospital of Eastern Ontario Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada; Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Jeff Critch
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Faculty of Medicine, Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Jennifer deBruyn
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Section of Pediatric Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Frances Tse
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Paul Moayyedi
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Peter Church
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; IBD Centre, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Colette Deslandres
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Centre Hospitalier Universitaire, Sainte-Justine, Montréal, Quebec, Canada
| | - Wael El-Matary
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Section of Pediatric Gastroenterology, Department of Pediatrics, Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - Hien Huynh
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Department of Pediatrics (Gastroenterology), Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Prévost Jantchou
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Centre Hospitalier Universitaire, Sainte-Justine, Montréal, Quebec, Canada
| | - Sally Lawrence
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anthony Otley
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Division of Gastroenterology and Nutrition, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Mary Sherlock
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Division of Pediatric Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Thomas Walters
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; IBD Centre, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, University of North Carolina, Hospital-Children's Specialty Clinic, Chapel Hill, North Carolina
| | - Dan Sadowski
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Anne Griffiths
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; IBD Centre, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
26
|
Mack DR, Benchimol EI, Critch J, deBruyn J, Tse F, Moayyedi P, Church P, Deslandres C, El-Matary W, Huynh H, Jantchou P, Lawrence S, Otley A, Sherlock M, Walters T, Kappelman MD, Sadowski D, Marshall JK, Griffiths A. Canadian Association of Gastroenterology Clinical Practice Guideline for the Medical Management of Pediatric Luminal Crohn's Disease. J Can Assoc Gastroenterol 2019; 2:e35-e63. [PMID: 31294379 PMCID: PMC6619414 DOI: 10.1093/jcag/gwz018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND & AIMS We aim to provide guidance for medical treatment of luminal Crohn's disease in children. METHODS We performed a systematic search of publication databases to identify studies of medical management of pediatric Crohn's disease. Quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. We developed statements through an iterative online platform and then finalized and voted on them. RESULTS The consensus includes 25 statements focused on medical treatment options. Consensus was not reached, and no recommendations were made, for 14 additional statements, largely due to lack of evidence. The group suggested corticosteroid therapies (including budesonide for mild to moderate disease). The group suggested exclusive enteral nutrition for induction therapy and biologic tumor necrosis factor antagonists for induction and maintenance therapy at diagnosis or at early stages of severe disease, and for patients failed by steroid and immunosuppressant induction therapies. The group recommended against the use of oral 5-aminosalicylate for induction or maintenance therapy in patients with moderate disease, and recommended against thiopurines for induction therapy, corticosteroids for maintenance therapy, and cannabis in any role. The group was unable to clearly define the role of concomitant immunosuppressants during initiation therapy with a biologic agent, although thiopurine combinations are not recommended for male patients. No consensus was reached on the role of aminosalicylates in treatment of patients with mild disease, antibiotics or vedolizumab for induction or maintenance therapy, or methotrexate for induction therapy. Patients in clinical remission who are receiving immunomodulators should be assessed for mucosal healing within 1 year of treatment initiation. CONCLUSIONS Evidence-based medical treatment of Crohn's disease in children is recommended, with thorough ongoing assessments to define treatment success.
Collapse
Affiliation(s)
- David R Mack
- Children's Hospital of Eastern Ontario Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
| | - Eric I Benchimol
- Children's Hospital of Eastern Ontario Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Jeff Critch
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Faculty of Medicine, Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Jennifer deBruyn
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Section of Pediatric Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Frances Tse
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Paul Moayyedi
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Peter Church
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- IBD Centre, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Colette Deslandres
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Centre Hospitalier Universitaire, Sainte-Justine, Montréal, Quebec, Canada
| | - Wael El-Matary
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Section of Pediatric Gastroenterology, Department of Pediatrics, Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - Hien Huynh
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Department of Pediatrics (Gastroenterology), Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Prévost Jantchou
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Centre Hospitalier Universitaire, Sainte-Justine, Montréal, Quebec, Canada
| | - Sally Lawrence
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anthony Otley
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Division of Gastroenterology and Nutrition, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Mary Sherlock
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Division of Pediatric Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Thomas Walters
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- IBD Centre, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, University of North Carolina, Hospital-Children's Specialty Clinic, Chapel Hill, North Carolina
| | - Dan Sadowski
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Anne Griffiths
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- IBD Centre, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
27
|
Pittayanon R, Lau JT, Yuan Y, Leontiadis GI, Tse F, Surette M, Moayyedi P. Gut Microbiota in Patients With Irritable Bowel Syndrome-A Systematic Review. Gastroenterology 2019; 157:97-108. [PMID: 30940523 DOI: 10.1053/j.gastro.2019.03.049] [Citation(s) in RCA: 363] [Impact Index Per Article: 72.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 02/23/2019] [Accepted: 03/15/2019] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Irritable bowel syndrome (IBS) is common but difficult to treat. Altering the gut microbiota has been proposed as a strategy for treatment of IBS, but the association between the gut microbiome and IBS symptoms has not been well established. We performed a systematic review to explore evidence for this association. METHODS We searched databases, including MEDLINE, EMBASE, Cochrane CDSR, and CENTRAL, through April 2, 2018 for case-control studies comparing the fecal or colon microbiomes of adult or pediatric patients with IBS with microbiomes of healthy individuals (controls). The primary outcome was differences in specific gut microbes between patients with IBS and controls. RESULTS The search identified 2631 citations; 24 studies from 22 articles were included. Most studies evaluated adults presenting with various IBS subtypes. Family Enterobacteriaceae (phylum Proteobacteria), family Lactobacillaceae, and genus Bacteroides were increased in patients with IBS compared with controls, whereas uncultured Clostridiales I, genus Faecalibacterium (including Faecalibacterium prausnitzii), and genus Bifidobacterium were decreased in patients with IBS. The diversity of the microbiota was either decreased or not different in IBS patients compared with controls. More than 40% of included studies did not state whether cases and controls were comparable (did not describe sex and/or age characteristics). CONCLUSIONS In a systematic review, we identified specific bacteria associated with microbiomes of patients with IBS vs controls. Studies are needed to determine whether these microbes are a product or cause of IBS.
Collapse
Affiliation(s)
- Rapat Pittayanon
- Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Jennifer T Lau
- Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Yuhong Yuan
- Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Grigorios I Leontiadis
- Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Frances Tse
- Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Michael Surette
- Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Paul Moayyedi
- Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
28
|
Andrews CN, Devlin SM, Le Foll B, Fischer B, Tse F, Storr M, Congly SE. Canadian Association of Gastroenterology Position Statement: Use of Cannabis in Gastroenterological and Hepatic Disorders. J Can Assoc Gastroenterol 2018; 2:37-43. [PMID: 31294362 PMCID: PMC6507278 DOI: 10.1093/jcag/gwy064] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/17/2018] [Indexed: 12/19/2022] Open
Affiliation(s)
- Christopher N Andrews
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Correspondence: Christopher N Andrews, MD, MSc, FRCPC, Clinical Professor, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, 6th Floor, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, Canada. E-mail
| | - Shane M Devlin
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bernard Le Foll
- Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Acute Care Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Departments of Family and Community Medicine, Pharmacology and Toxicology, Psychiatry, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Benedikt Fischer
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Frances Tse
- Department of Gastroenterology and Hepatology, McMaster University, Hamilton, Ontario, Canada
| | - Martin Storr
- Department of Medicine, University of Munich and Center of Endoscopy, Starnberg, Germany
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
29
|
Leddin D, Lieberman DA, Tse F, Barkun AN, Abou-Setta AM, Marshall JK, Samadder NJ, Singh H, Telford JJ, Tinmouth J, Wilkinson AN, Leontiadis GI. Clinical Practice Guideline on Screening for Colorectal Cancer in Individuals With a Family History of Nonhereditary Colorectal Cancer or Adenoma: The Canadian Association of Gastroenterology Banff Consensus. Gastroenterology 2018; 155:1325-1347.e3. [PMID: 30121253 DOI: 10.1053/j.gastro.2018.08.017] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS A family history (FH) of colorectal cancer (CRC) increases the risk of developing CRC. These consensus recommendations developed by the Canadian Association of Gastroenterology and endorsed by the American Gastroenterological Association, aim to provide guidance on screening these high-risk individuals. METHODS Multiple parallel systematic review streams, informed by 10 literature searches, assembled evidence on 5 principal questions around the effect of an FH of CRC or adenomas on the risk of CRC, the age to initiate screening, and the optimal tests and testing intervals. The GRADE (Grading of Recommendation Assessment, Development and Evaluation) approach was used to develop the recommendations. RESULTS Based on the evidence, the Consensus Group was able to strongly recommend CRC screening for all individuals with an FH of CRC or documented adenoma. However, because most of the evidence was very-low quality, the majority of the remaining statements were conditional ("we suggest"). Colonoscopy is suggested (recommended in individuals with ≥2 first-degree relatives [FDRs]), with fecal immunochemical test as an alternative. The elevated risk associated with an FH of ≥1 FDRs with CRC or documented advanced adenoma suggests initiating screening at a younger age (eg, 40-50 years or 10 years younger than age of diagnosis of FDR). In addition, a shorter interval of every 5 years between screening tests was suggested for individuals with ≥2 FDRs, and every 5-10 years for those with FH of 1 FDR with CRC or documented advanced adenoma compared to average-risk individuals. Choosing screening parameters for an individual patient should consider the age of the affected FDR and local resources. It is suggested that individuals with an FH of ≥1 second-degree relatives only, or of nonadvanced adenoma or polyp of unknown histology, be screened according to average-risk guidelines. CONCLUSIONS The increased risk of CRC associated with an FH of CRC or advanced adenoma warrants more intense screening for CRC. Well-designed prospective studies are needed in order to make definitive evidence-based recommendations about the age to commence screening and appropriate interval between screening tests.
Collapse
Affiliation(s)
- Desmond Leddin
- Graduate Entry Medical School, University of Limerick, Ireland; Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - David A Lieberman
- Division of Gastroenterology, Oregon Health and Science University, Portland, Oregon
| | - Frances Tse
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Ahmed M Abou-Setta
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - N Jewel Samadder
- Division of Gastroenterology and Hepatology, Department of Clinical Genomics, Mayo Clinic, Phoenix, Arizona
| | - Harminder Singh
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Section of Gastroenterology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jennifer J Telford
- Division of Gastroenterology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jill Tinmouth
- Department of Medicine, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada
| | - Anna N Wilkinson
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
30
|
Liu LWC, Andrews CN, Armstrong D, Diamant N, Jaffer N, Lazarescu A, Li M, Martino R, Paterson W, Leontiadis GI, Tse F. Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia. J Can Assoc Gastroenterol 2018; 1:5-19. [PMID: 31294391 PMCID: PMC6487990 DOI: 10.1093/jcag/gwx008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND AIMS Our aim is to review the literature and provide guidelines for the assessment of uninvestigated dysphagia. METHODS A systematic literature search identified studies on dysphagia. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Statements were discussed and revised via small group meetings, teleconferences, and a web-based platform until consensus was reached by the full group. RESULTS The consensus includes 13 statements focused on the role of strategies for the assessment of esophageal dysphagia. In patients presenting with dysphagia, oropharyngeal dysphagia should be identified promptly because of the risk of aspiration. For patients with esophageal dysphagia, history can be used to help differentiate structural from motility disorders and to elicit alarm features. An empiric trial of proton pump inhibitor therapy should be limited to four weeks in patients with esophageal dysphagia who have reflux symptoms and no additional alarm features. For patients with persistent dysphagia, endoscopy, including esophageal biopsy, was recommended over barium esophagram for the assessment of structural and mucosal esophageal disease. Barium esophagram may be useful when the availability of endoscopy is limited. Esophageal manometry was recommended for diagnosis of esophageal motility disorders, and high-resolution was recommended over conventional manometry. CONCLUSIONS Once oropharyngeal dysphagia is ruled out, patients with symptoms of esophageal dysphagia should be assessed by history and physical examination, followed by endoscopy to identify structural and inflammatory lesions. If these are ruled out, then manometry is recommended for the diagnosis of esophageal dysmotility.
Collapse
Affiliation(s)
- Louis W C Liu
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON
| | - Christopher N Andrews
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, AB
| | | | - Nicholas Diamant
- Division of Gastroenterology, Department of Medicine, Queen’s University, Kingston, ON
| | - Nasir Jaffer
- Department of Medical Imaging, Mount Sinai Hospital, Toronto, ON
| | | | - Marilyn Li
- Division of Gastroenterology, Department of Medicine, Queen’s University, Kingston, ON
| | - Rosemary Martino
- Department of Speech-Language Pathology, University of Toronto, Toronto, ON
| | - William Paterson
- Division of Gastroenterology, Department of Medicine, Queen’s University, Kingston, ON
| | | | - Frances Tse
- Department of Medicine, McMaster University, Hamilton, ON
| |
Collapse
|
31
|
YAGHOOBI M, Alzahrani MA, McNabb-Baltar J, Martel M, Tse F, Barkun AN. A323 A PERSONALIZED MEDICINE APPROACH TO THE ROLE OF RECTAL INDOMETHACIN IN PREVENTING POST -ERCP PANCREATITIS: A META- ANALYSIS OF AGGREGATE SUBGROUP DATA. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy008.324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- M YAGHOOBI
- McMaster University, Hamilton, ON, Canada
| | - M A Alzahrani
- Gastroenterology, McMaster university, Hamilton, ON, Canada
| | - J McNabb-Baltar
- Brigham and Women’s Hospital, Harvard Medical School, Montreal, QC, Canada
| | - M Martel
- McGill University Health Center, Montreal, QC, Canada
| | - F Tse
- McMaster University, Hamilton, ON, Canada
| | - A N Barkun
- Gastroenterology, McGill University, The Montreal General Hospital, GI Division, Montreal, QC, Canada
| |
Collapse
|
32
|
Leddin D, Lieberman D, Leontiadis G, Tse F, Barkun AN, Marshall J, Samadder N, Singh H, Telford JJ, Tinmouth J, Abou-Setta A, Wilkinson AN. A2 GATHERING AND ASSESSING EVIDENCE TO INFORM A GUIDELINE ON SCREENING FOR COLORECTAL CANCER IN INDIVIDUALS WITH A FAMILY HISTORY. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy009.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- D Leddin
- Dalhousie Univ, Halifax, NS, Canada
| | - D Lieberman
- Oregon Health & Science University, Portland, OR
| | | | - F Tse
- McMaster University, Hamilton, ON, Canada
| | - A N Barkun
- Gastroenterology, McGill University, The Montreal General Hospital, GI Division, Montreal, QC, Canada
| | - J Marshall
- McMaster University Medical Centre, Hamilton, ON, Canada
| | | | - H Singh
- University of Manitoba, Winnipeg, MB, Canada
| | - J J Telford
- University of British Columbia, Vancouver, BC, Canada
| | - J Tinmouth
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | | |
Collapse
|
33
|
Hu A, Yuan Y, Leontiadis G, Tse F. A330 PREVENTION OF POST-ERCP PANCREATITIS: DO PROTEASE INHIBITORS HAVE A ROLE? J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy009.330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- A Hu
- McMaster University, Toronto, ON, Canada
| | - Y Yuan
- McMaster University, Hamilton, ON, Canada
| | | | - F Tse
- McMaster University, Hamilton, ON, Canada
| |
Collapse
|
34
|
Enns RA, Hookey L, Armstrong D, Bernstein CN, Heitman SJ, Teshima C, Leontiadis GI, Tse F, Sadowski D. Clinical Practice Guidelines for the Use of Video Capsule Endoscopy. Gastroenterology 2017; 152:497-514. [PMID: 28063287 DOI: 10.1053/j.gastro.2016.12.032] [Citation(s) in RCA: 242] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Video capsule endoscopy (CE) provides a noninvasive option to assess the small intestine, but its use with respect to endoscopic procedures and cross-sectional imaging varies widely. The aim of this consensus was to provide guidance on the appropriate use of CE in clinical practice. METHODS A systematic literature search identified studies on the use of CE in patients with Crohn's disease, celiac disease, gastrointestinal bleeding, and anemia. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. RESULTS The consensus includes 21 statements focused on the use of small-bowel CE and colon capsule endoscopy. CE was recommended for patients with suspected, known, or relapsed Crohn's disease when ileocolonoscopy and imaging studies were negative if it was imperative to know whether active Crohn's disease was present in the small bowel. It was not recommended in patients with chronic abdominal pain or diarrhea, in whom there was no evidence of abnormal biomarkers typically associated with Crohn's disease. CE was recommended to assess patients with celiac disease who have unexplained symptoms despite appropriate treatment, but not to make the diagnosis. In patients with overt gastrointestinal bleeding, and negative findings on esophagogastroduodenoscopy and colonoscopy, CE should be performed as soon as possible. CE was recommended only in selected patients with unexplained, mild, chronic iron-deficiency anemia. CE was suggested for surveillance in patients with polyposis syndromes or other small-bowel cancers, who required small-bowel studies. Colon capsule endoscopy should not be substituted routinely for colonoscopy. Patients should be made aware of the potential risks of CE including a failed procedure, capsule retention, or a missed lesion. Finally, standardized criteria for training and reporting in CE should be defined. CONCLUSIONS CE generally should be considered a complementary test in patients with gastrointestinal bleeding, Crohn's disease, or celiac disease, who have had negative or inconclusive endoscopic or imaging studies.
Collapse
Affiliation(s)
- Robert A Enns
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Lawrence Hookey
- Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David Armstrong
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Charles N Bernstein
- Section of Gastroenterology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Steven J Heitman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Teshima
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Frances Tse
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Sadowski
- Division of Gastroenterology, Royal Alexandria Hospital, Edmonton, Alberta, Canada
| |
Collapse
|
35
|
Tse F, Yuan Y, Moayyedi P, Leontiadis GI, Barkun AN. Double-guidewire technique in difficult biliary cannulation for the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis. Endoscopy 2017; 49:15-26. [PMID: 27997966 DOI: 10.1055/s-0042-119035] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background and study aims Difficult cannulation is a risk factor for pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP). The double-guidewire technique (DGT) may improve cannulation success and reduce the risk of post-ERCP pancreatitis (PEP) in patients with difficult cannulation. This systematic review compared the DGT with persistent conventional cannulation or other advanced techniques in patients with difficult cannulation. Patients and Methods CENTRAL, MEDLINE, EMBASE, and CINAHL databases and DDW and UEGW abstracts up to March 2016 were searched for randomized controlled trials (RCTs) comparing DGT with persistent conventional cannulation or other advanced techniques (precut, pancreatic duct [PD] stenting). The primary outcome was PEP. Secondary outcomes included severity of PEP, successful cannulation of the common bile duct (CBD) with the randomized technique, overall CBD cannulation success, and ERCP-related complications. Results 7 RCTs (577 patients) were included. Use of the DGT significantly increased PEP compared to other endoscopic techniques (risk ratio [RR] 1.98, 95 % confidence interval [95 %CI] 1.14 - 3.42). There was no significant difference in CBD cannulation success with the randomized technique (RR 1.04, 95 %CI 0.87 - 1.24) or in overall cannulation success (RR 1.04, 95 %CI 0.91 - 1.18) between DGT and other techniques. There was also no significant difference in the risk of other ERCP-related complications (bleeding, perforation, cholangitis, and mortality). The results were robust in sensitivity analyses. Conclusions In patients with difficult cannulation, sole use of the DGT appears to increase the risk of PEP without any superiority in achieving biliary cannulation compared to other techniques. PD stenting may reduce the risk of PEP when the DGT is used. The influence of co-intervention in the form of per-procedural nonsteroidal anti-inflammatory drug (NSAID) administration is unclear.
Collapse
Affiliation(s)
- Frances Tse
- Division of Gastroenterology, McMaster University, Hamilton Health Sciences Centre, Hamilton, Ontario, Canada
| | - Yuhong Yuan
- Division of Gastroenterology, McMaster University, Hamilton Health Sciences Centre, Hamilton, Ontario, Canada
| | - Paul Moayyedi
- Division of Gastroenterology, McMaster University, Hamilton Health Sciences Centre, Hamilton, Ontario, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology, McMaster University, Hamilton Health Sciences Centre, Hamilton, Ontario, Canada
| | - Alan N Barkun
- McGill University and McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
36
|
Tse F, Yuan Y, Bukhari M, Leontiadis GI, Moayyedi P, Barkun A. Pancreatic duct guidewire placement for biliary cannulation for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Cochrane Database Syst Rev 2016; 2016:CD010571. [PMID: 27182692 PMCID: PMC10440590 DOI: 10.1002/14651858.cd010571.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Difficult cannulation is a risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). It has been postulated that the pancreatic duct guidewire (PGW) technique may improve biliary cannulation success and reduce the risk of PEP in people with difficult cannulation. OBJECTIVES To systematically review evidence from randomised controlled trials (RCTs) assessing the effectiveness and safety of the PGW technique compared to persistent conventional cannulation (CC) (contrast- or guidewire-assisted cannulation) or other advanced techniques in people with difficult biliary cannulation for the prevention of PEP. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL databases, major conference proceedings, and for ongoing trials on the ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) up to March 2016, using the Cochrane Upper Gastrointestinal and Pancreatic Diseases model with no language restrictions. SELECTION CRITERIA RCTs comparing the PGW technique versus persistent CC or other advanced techniques in people undergoing ERCP with difficult biliary cannulation. DATA COLLECTION AND ANALYSIS Two review authors independently conducted study selection, data extraction, and methodological quality assessment. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi(2) test (P < 0.15) and I(2) test (> 25%). To explore sources of heterogeneity, we conducted a priori subgroup analyses according to trial design, use of pancreatic duct (PD) stent, involvement of trainees in cannulation, publication type, and risk of bias. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed-effect versus random-effects). MAIN RESULTS We included seven RCTs comprising 577 participants. There was no significant heterogeneity among trials for the outcome of PEP (P = 0.32; I(2) = 15%). The PGW technique significantly increased PEP compared to other endoscopic techniques (RR 1.98, 95% CI 1.14 to 3.42; low-quality evidence). The number needed to treat for an additional harmful outcome was 13 (95% CI 5 to 89). Among the three studies that compared the PGW technique with persistent CC, the incidence of PEP was 13.5% for the PGW technique and 8.7% for persistent CC (RR 1.58, 95% CI 0.83 to 3.01; low-quality evidence). Among the two studies that compared the PGW technique with precut sphincterotomy, the incidence of PEP was 29.8% in the PGW group versus 10.3% in the precut group (RR 2.92, 95% CI 1.24 to 6.88; low-quality evidence). Among the two studies that compared the PGW technique with PD stent placement, the incidence of PEP was 11.7% for the PGW technique and 5.0% for PD stent placement (RR 1.75, 95% CI 0.08 to 37.50; very low-quality evidence). There was no significant difference in common bile duct (CBD) cannulation success with the randomised technique (RR 1.04, 95% CI 0.87 to 1.24; low-quality evidence) or overall CBD cannulation success (RR 1.04, 95% CI 0.91 to 1.18; low-quality evidence) between the PGW technique and other endoscopic techniques. There was also no statistically significant difference in the risk of other ERCP-related complications (bleeding, perforation, cholangitis, and mortality). The results were robust in sensitivity analyses. The overall quality of evidence for the outcome of PEP was low or very low because of study limitations and imprecision. AUTHORS' CONCLUSIONS In people with difficult CBD cannulation, sole use of the PGW technique appears to be associated with an increased risk of PEP. Prophylactic PD stenting after use of the PGW technique may reduce the risk of PEP. However, the PGW technique is not superior to persistent attempts with CC, precut sphincterotomy, or PD stent in achieving CBD cannulation. The influence of co-intervention in the form of rectal peri-procedural nonsteroidal anti-inflammatory drug administration is unclear.
Collapse
Affiliation(s)
- Frances Tse
- McMaster UniversityDepartment of Medicine, Division of Gastroenterology1200 Main Street West2F53HamiltonONCanadaL8N 3Z5
| | - Yuhong Yuan
- McMaster UniversityDepartment of Medicine, Division of Gastroenterology1200 Main Street West2F53HamiltonONCanadaL8N 3Z5
| | - Majidah Bukhari
- McMaster UniversityDepartment of Medicine, Division of Gastroenterology1200 Main Street West2F53HamiltonONCanadaL8N 3Z5
| | - Grigorios I Leontiadis
- McMaster UniversityDepartment of Medicine, Division of Gastroenterology1200 Main Street West2F53HamiltonONCanadaL8N 3Z5
| | - Paul Moayyedi
- McMaster UniversityDepartment of Medicine, Division of Gastroenterology1200 Main Street West2F53HamiltonONCanadaL8N 3Z5
| | - Alan Barkun
- The Montreal General HospitalClinical Epidemiology1650 Cedar Ave Rm D7‐148MontrealQCCanadaH3G 1A4
| | | |
Collapse
|
37
|
Nguyen GC, Seow CH, Maxwell C, Huang V, Leung Y, Jones J, Leontiadis GI, Tse F, Mahadevan U, van der Woude CJ. The Toronto Consensus Statements for the Management of Inflammatory Bowel Disease in Pregnancy. Gastroenterology 2016; 150:734-757.e1. [PMID: 26688268 DOI: 10.1053/j.gastro.2015.12.003] [Citation(s) in RCA: 306] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The management of inflammatory bowel disease (IBD) poses a particular challenge during pregnancy because the health of both the mother and the fetus must be considered. METHODS A systematic literature search identified studies on the management of IBD during pregnancy. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. RESULTS Consensus was reached on 29 of the 30 recommendations considered. Preconception counseling and access to specialist care are paramount in optimizing disease management. In general, women on 5-ASA, thiopurine, or anti-tumor necrosis factor (TNF) monotherapy for maintenance should continue therapy throughout pregnancy. Discontinuation of anti-TNF therapy or switching from combination therapy to monotherapy may be considered in very select low-risk patients. Women who have a mild to moderate disease flare while on optimized 5-ASA or thiopurine therapy should be managed with systemic corticosteroid or anti-TNF therapy, and those with a corticosteroid-resistant flare should start anti-TNF therapy. Endoscopy or urgent surgery should not be delayed during pregnancy if indicated. Decisions regarding cesarean delivery should be based on obstetric considerations and not the diagnosis of IBD alone, with the exception of women with active perianal Crohn's disease. With the exception of methotrexate, the use of medications for IBD should not influence the decision to breast-feed and vice versa. Live vaccinations are not recommended within the first 6 months of life in the offspring of women who were on anti-TNF therapy during pregnancy. CONCLUSIONS Optimal management of IBD before and during pregnancy is essential to achieving favorable maternal and neonatal outcomes.
Collapse
Affiliation(s)
- Geoffrey C Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Cynthia H Seow
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Vivian Huang
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Yvette Leung
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Frances Tse
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Uma Mahadevan
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | |
Collapse
|
38
|
Forbes N, Cooray M, Al-Dabbagh R, Yuan Y, Tse F, Liu LW, Xenodemetropoulos T. Domperidone prescribing practices exposed patients to cardiac risk despite a 'black box' warning: A Canadian tertiary care centre study. Can J Gastroenterol Hepatol 2015:17133. [PMID: 26418535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
|
39
|
Alhazzani W, Al-Shamsi HO, Greenwald E, Radhi J, Tse F. Chronic abdominal pain secondary to mesenteric panniculitis treated successfully with endoscopic ultrasonography-guided celiac plexus block: A case report. World J Gastrointest Endosc 2015; 7:563-566. [PMID: 25992196 PMCID: PMC4436925 DOI: 10.4253/wjge.v7.i5.563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 10/21/2014] [Accepted: 03/05/2015] [Indexed: 02/05/2023] Open
Abstract
Mesenteric panniculitis is a chronic illness that is characterized by fibrosing inflammation of the mesenteries that can lead to intractable abdominal pain. Pain control is a crucial component of the management plan. Most patients will improve with oral corticosteroids treatment, however, some patients will require a trial of other immunosuppressive agents, and a minority of patients will continue to have refractory disease. Endoscopic ultrasound guided celiac plexus block is used frequently to control abdominal pain in patients with pancreatic pathology. To our knowledge there are no case reports describing its use in mesenteric panniculitis patients with refractory abdominal pain.
Collapse
|
40
|
Anglin R, Yuan Y, Moayyedi P, Tse F, Armstrong D, Leontiadis GI. Risk of upper gastrointestinal bleeding with selective serotonin reuptake inhibitors with or without concurrent nonsteroidal anti-inflammatory use: a systematic review and meta-analysis. Am J Gastroenterol 2014; 109:811-9. [PMID: 24777151 DOI: 10.1038/ajg.2014.82] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 03/11/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES There is emerging concern that selective serotonin reuptake inhibitors (SSRIs) may be associated with an increased risk of upper gastrointestinal (GI) bleeding, and that this risk may be further increased by concurrent use of nonsteroidal anti-inflammatory (NSAID) medications. Previous reviews of a relatively small number of studies have reported a substantial risk of upper GI bleeding with SSRIs; however, more recent studies have produced variable results. The objective of this study was to obtain a more precise estimate of the risk of upper GI bleeding with SSRIs, with or without concurrent NSAID use. METHODS MEDLINE, EMBASE, PsycINFO, the Cochrane central register of controlled trials (through April 2013), and US and European conference proceedings were searched. Controlled trials, cohort, case-control, and cross-sectional studies that reported the incidence of upper GI bleeding in adults on SSRIs with or without concurrent NSAID use, compared with placebo or no treatment were included. Data were extracted independently by two authors. Dichotomous data were pooled to obtain odds ratio (OR) of the risk of upper GI bleeding with SSRIs +/- NSAID, with a 95% confidence interval (CI). The main outcome and measure of the study was the risk of upper GI bleeding with SSRIs compared with placebo or no treatment. RESULTS Fifteen case-control studies (including 393,268 participants) and four cohort studies were included in the analysis. There was an increased risk of upper GI bleeding with SSRI medications in the case-control studies (OR=1.66, 95% CI=1.44,1.92) and cohort studies (OR=1.68, 95% CI=1.13,2.50). The number needed to harm for upper GI bleeding with SSRI treatment in a low-risk population was 3,177, and in a high-risk population it was 881. The risk of upper GI bleeding was further increased with the use of both SSRI and NSAID medications (OR=4.25, 95% CI=2.82,6.42). CONCLUSIONS SSRI medications are associated with a modest increase in the risk of upper GI bleeding, which is lower than has previously been estimated. This risk is significantly elevated when SSRI medications are used in combination with NSAIDs, and physicians prescribing these medications together should exercise caution and discuss this risk with patients.
Collapse
Affiliation(s)
- Rebecca Anglin
- 1] Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada [2] Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Yuhong Yuan
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Paul Moayyedi
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Frances Tse
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - David Armstrong
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
41
|
Affiliation(s)
- Frances Tse
- Hamilton Health Sciences Centre, Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Yuhong Yuan
- Hamilton Health Sciences Centre, Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Grigorios I Leontiadis
- Hamilton Health Sciences Centre, Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
42
|
Tse F, Yuan Y, Moayyedi P, Leontiadis GI. Reply to Kawakami et al. Endoscopy 2014; 46:164. [PMID: 24477371 DOI: 10.1055/s-0033-1358952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
|
43
|
Yuan Y, Ford AC, Khan KJ, Gisbert JP, Forman D, Leontiadis GI, Tse F, Calvet X, Fallone C, Fischbach L, Oderda G, Bazzoli F, Moayyedi P. Optimum duration of regimens for Helicobacter pylori eradication. Cochrane Database Syst Rev 2013. [PMID: 24338763 DOI: 10.1002/14651858.cd008337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The optimal duration for Helicobacter pylori (H. pylori) eradication therapy is controversial, with recommendations ranging from 7 to 14 days. Several systematic reviews have attempted to address this issue but have given conflicting results and limited their analysis to proton pump inhibitor (PPI), two antibiotics (PPI triple) therapy. We performed a systematic review and meta-analysis to investigate the optimal duration of multiple H. pylori eradication regimens. OBJECTIVES The primary objective was to assess the relative effectiveness of different durations (7, 10 or 14 days) of a variety of regimens for eradicating H. pylori. The primary outcome was H. pylori persistence. The secondary outcome was adverse events. SEARCH METHODS The Cochrane Library, MEDLINE, EMBASE, and CINAHL were searched up to December 2011 to identify eligible randomised controlled trials (RCTs). We also searched the proceedings of six conferences from 1995 to 2011, dissertations and theses, and grey literature. There were no language restrictions applied to any search. SELECTION CRITERIA Only parallel group RCTs assessing the efficacy of one to two weeks duration of first line H. pylori eradication regimens in adults were eligible. Within each regimen, the same combinations of drugs at the same dose were compared over different durations. Studies with at least two arms comparing 7, 10, or 14 days were eligible. Enrolled participants needed to be diagnosed with at least one positive test for H. pylori on the basis of a rapid urease test (RUT), histology, culture, urea breath test (UBT), or a stool antigen test (HpSA) before treatment. Eligible trials needed to confirm eradication of H. pylori as their primary outcome at least 28 days after completion of eradication treatment. Trials using only serology or a polymerase chain reaction (PCR) to determine H. pylori infection or eradication were excluded. DATA COLLECTION AND ANALYSIS Study eligibility and data extraction were performed by two independent review authors. Data analyses were performed within each type of intervention, for both primary and secondary outcomes. The relative risk (RR) and number needed to treat (NNT)/number needed to harm (NNTH) according to duration of therapy were calculated using the outcomes of H. pylori persistence and adverse events. A random-effects model was used. Subgroup analyses and sensitivity analyses were planned a priori. MAIN RESULTS In total, 75 studies met the inclusion criteria. Eight types of regimens were reported with at least two comparative eligible durations. They included: PPI + two antibiotics triple therapy (n = 59), PPI bismuth-based quadruple therapy (n = 6), PPI + three antibiotics quadruple therapy (n = 1), PPI dual therapy (n = 2), histamine H2-receptor antagonist (H₂RA) bismuth quadruple therapy (n = 3), H₂RA bismuth-based triple therapy (n = 2), H₂RA + two antibiotics triple therapy (n = 3), and bismuth + two antibiotics triple therapy (n = 2). Some studies provided data for more than one regimen or more than two durations.For the PPI triple therapy, 59 studies with five regimens were reported: PPI + clarithromycin + amoxicillin (PCA); PPI + clarithromycin + a nitroimidazole (PCN); PPI + amoxicillin + nitroimidazole (PAN); PPI + amoxicillin + a quinolone (PAQ); and PPI + amoxicillin + a nitrofuran (PANi). Regardless of type and dose of antibiotics, increased duration of PPI triple therapy from 7 to 14 days significantly increased the H. pylori eradication rate (45 studies, 72.9% versus 81.9%), the RR for H. pylori persistence was 0.66 (95% CI 0.60 to 0.74), NNT was 11 (95% CI 9 to 14). Significant effects were seen in the subgroup of PCA (34 studies, RR 0.65, 95% CI 0.57 to 0.75; NNT 12, 95% CI 9 to 16); PAN (10 studies, RR 0.67, 95% CI 0.52 to 0.86; NNT = 11, 95% CI 8 to 25); and in PAQ (2 studies, RR 0.37, 95% CI 0.16 to 0.83; NNT 3, 95% CI 2 to 10); but not in PCN triple therapy (4 studies, RR 0.87, 95% CI 0.71 to 1.07). Significantly increased eradication rates were also seen for PPI triple therapy with 10 versus 7 days (24 studies, 79.9% versus 75.7%; RR 0.80, 95% CI 0.72 to 0.89; NNT 21, 95% CI 15 to 38) and 14 versus 10 days (12 studies, 84.4% versus 78.5%; RR 0.72, 95% CI 0.58 to 0.90; NNT 17, 95% CI 11 to 46); especially in the subgroup of PAC for 10 versus 7 days (17 studies, RR 0.80, 95% CI 0.70 to 0.91) and for 14 versus 10 days (10 studies, RR 0.69, 95% CI 0.52 to 0.91). A trend towards increased H. pylori eradication rates was seen with increased duration of PCN for 10 versus 7 days, and of PAN for 10 versus 7 days and 14 versus 10 days, though this was not statistical significant. The proportion of patients with adverse events, defined by authors, was marginally significantly increased only between 7 days and 14 days (15.5% versus 19.4%; RR 1.21, 95% CI 1.06 to 1.37; NNTH 31, 95% CI 18 to 104) but not for other duration comparisons. The proportion of patients discontinuing treatment due to adverse events was not significantly different between treatment durations.Only limited data were reported for different durations of regimens other than PPI triple therapy. No significant difference of the eradication rate was seen for all regimens according to different durations except for H₂RA bismuth quadruple therapy, where a significantly higher eradication rate was seen for 14 days versus 7 days, however only one study reported outcome data. AUTHORS' CONCLUSIONS Increasing the duration of PPI-based triple therapy increases H. pylori eradication rates. For PCA, prolonging treatment duration from 7 to 10 or from 10 to 14 days is associated with a significantly higher eradication rate. The optimal duration of therapy for PCA and PAN is at least 14 days. More data are needed to confirm if there is any benefit of increasing the duration of therapy for PCN therapy. Information is limited for regimens other than PPI triple therapy; more studies are needed to draw meaningful conclusions for optimal duration of other H. pylori eradication regimens.
Collapse
Affiliation(s)
- Yuhong Yuan
- Department of Medicine, Division of Gastroenterology, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada, L8S 4K1
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Yuan Y, Ford AC, Khan KJ, Gisbert JP, Forman D, Leontiadis GI, Tse F, Calvet X, Fallone C, Fischbach L, Oderda G, Bazzoli F, Moayyedi P. Optimum duration of regimens for Helicobacter pylori eradication. Cochrane Database Syst Rev 2013:CD008337. [PMID: 24338763 DOI: 10.1002/14651858.cd008337.pub2] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The optimal duration for Helicobacter pylori (H. pylori) eradication therapy is controversial, with recommendations ranging from 7 to 14 days. Several systematic reviews have attempted to address this issue but have given conflicting results and limited their analysis to proton pump inhibitor (PPI), two antibiotics (PPI triple) therapy. We performed a systematic review and meta-analysis to investigate the optimal duration of multiple H. pylori eradication regimens. OBJECTIVES The primary objective was to assess the relative effectiveness of different durations (7, 10 or 14 days) of a variety of regimens for eradicating H. pylori. The primary outcome was H. pylori persistence. The secondary outcome was adverse events. SEARCH METHODS The Cochrane Library, MEDLINE, EMBASE, and CINAHL were searched up to December 2011 to identify eligible randomised controlled trials (RCTs). We also searched the proceedings of six conferences from 1995 to 2011, dissertations and theses, and grey literature. There were no language restrictions applied to any search. SELECTION CRITERIA Only parallel group RCTs assessing the efficacy of one to two weeks duration of first line H. pylori eradication regimens in adults were eligible. Within each regimen, the same combinations of drugs at the same dose were compared over different durations. Studies with at least two arms comparing 7, 10, or 14 days were eligible. Enrolled participants needed to be diagnosed with at least one positive test for H. pylori on the basis of a rapid urease test (RUT), histology, culture, urea breath test (UBT), or a stool antigen test (HpSA) before treatment. Eligible trials needed to confirm eradication of H. pylori as their primary outcome at least 28 days after completion of eradication treatment. Trials using only serology or a polymerase chain reaction (PCR) to determine H. pylori infection or eradication were excluded. DATA COLLECTION AND ANALYSIS Study eligibility and data extraction were performed by two independent review authors. Data analyses were performed within each type of intervention, for both primary and secondary outcomes. The relative risk (RR) and number needed to treat (NNT)/number needed to harm (NNTH) according to duration of therapy were calculated using the outcomes of H. pylori persistence and adverse events. A random-effects model was used. Subgroup analyses and sensitivity analyses were planned a priori. MAIN RESULTS In total, 75 studies met the inclusion criteria. Eight types of regimens were reported with at least two comparative eligible durations. They included: PPI + two antibiotics triple therapy (n = 59), PPI bismuth-based quadruple therapy (n = 6), PPI + three antibiotics quadruple therapy (n = 1), PPI dual therapy (n = 2), histamine H2-receptor antagonist (H₂RA) bismuth quadruple therapy (n = 3), H₂RA bismuth-based triple therapy (n = 2), H₂RA + two antibiotics triple therapy (n = 3), and bismuth + two antibiotics triple therapy (n = 2). Some studies provided data for more than one regimen or more than two durations.For the PPI triple therapy, 59 studies with five regimens were reported: PPI + clarithromycin + amoxicillin (PCA); PPI + clarithromycin + a nitroimidazole (PCN); PPI + amoxicillin + nitroimidazole (PAN); PPI + amoxicillin + a quinolone (PAQ); and PPI + amoxicillin + a nitrofuran (PANi). Regardless of type and dose of antibiotics, increased duration of PPI triple therapy from 7 to 14 days significantly increased the H. pylori eradication rate (45 studies, 72.9% versus 81.9%), the RR for H. pylori persistence was 0.66 (95% CI 0.60 to 0.74), NNT was 11 (95% CI 9 to 14). Significant effects were seen in the subgroup of PCA (34 studies, RR 0.65, 95% CI 0.57 to 0.75; NNT 12, 95% CI 9 to 16); PAN (10 studies, RR 0.67, 95% CI 0.52 to 0.86; NNT = 11, 95% CI 8 to 25); and in PAQ (2 studies, RR 0.37, 95% CI 0.16 to 0.83; NNT 3, 95% CI 2 to 10); but not in PCN triple therapy (4 studies, RR 0.87, 95% CI 0.71 to 1.07). Significantly increased eradication rates were also seen for PPI triple therapy with 10 versus 7 days (24 studies, 79.9% versus 75.7%; RR 0.80, 95% CI 0.72 to 0.89; NNT 21, 95% CI 15 to 38) and 14 versus 10 days (12 studies, 84.4% versus 78.5%; RR 0.72, 95% CI 0.58 to 0.90; NNT 17, 95% CI 11 to 46); especially in the subgroup of PAC for 10 versus 7 days (17 studies, RR 0.80, 95% CI 0.70 to 0.91) and for 14 versus 10 days (10 studies, RR 0.69, 95% CI 0.52 to 0.91). A trend towards increased H. pylori eradication rates was seen with increased duration of PCN for 10 versus 7 days, and of PAN for 10 versus 7 days and 14 versus 10 days, though this was not statistical significant. The proportion of patients with adverse events, defined by authors, was marginally significantly increased only between 7 days and 14 days (15.5% versus 19.4%; RR 1.21, 95% CI 1.06 to 1.37; NNTH 31, 95% CI 18 to 104) but not for other duration comparisons. The proportion of patients discontinuing treatment due to adverse events was not significantly different between treatment durations.Only limited data were reported for different durations of regimens other than PPI triple therapy. No significant difference of the eradication rate was seen for all regimens according to different durations except for H₂RA bismuth quadruple therapy, where a significantly higher eradication rate was seen for 14 days versus 7 days, however only one study reported outcome data. AUTHORS' CONCLUSIONS Increasing the duration of PPI-based triple therapy increases H. pylori eradication rates. For PCA, prolonging treatment duration from 7 to 10 or from 10 to 14 days is associated with a significantly higher eradication rate. The optimal duration of therapy for PCA and PAN is at least 14 days. More data are needed to confirm if there is any benefit of increasing the duration of therapy for PCN therapy. Information is limited for regimens other than PPI triple therapy; more studies are needed to draw meaningful conclusions for optimal duration of other H. pylori eradication regimens.
Collapse
Affiliation(s)
- Yuhong Yuan
- Department of Medicine, Division of Gastroenterology, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada, L8S 4K1
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Tse F, Yuan Y, Moayyedi P, Leontiadis GI. Guide wire-assisted cannulation for the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis. Endoscopy 2013; 45:605-18. [PMID: 23807804 DOI: 10.1055/s-0032-1326640] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND STUDY AIMS Cannulation techniques are recognized to be important in causing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, considerable controversy exists about the usefulness of the guide wire-assisted cannulation technique for the prevention of PEP. This systematic review of randomized controlled trials (RCTs) aimed to compare the guide wire-assisted cannulation technique with the contrast-assisted cannulation technique. METHODS CENTRAL, MEDLINE, EMBASE, CINAHL, and abstracts from Digestive Disease Week and the United European Gastroenterology Week were searched up to February 2012 for RCTs comparing the guide wire-assisted ERCP cannulation technique with the conventional contrast-assisted ERCP cannulation technique. The risk of bias was assessed, and outcomes were pooled by meta-analysis (random-effects model). The primary outcome measure was PEP. Secondary outcome measures included severity of PEP, primary common bile duct (CBD) cannulation success, overall CBD cannulation success, precut sphincterotomy, and other ERCP-related complications. RESULTS In total, 12 RCTs (3450 patients) were included. The guide wire-assisted cannulation technique significantly reduced PEP compared with the contrast-assisted cannulation technique (risk ratio [RR] 0.51, 95 % confidence interval [CI] 0.32 - 0.82). In addition, the guide wire-assisted cannulation technique was associated with greater primary cannulation success (RR 1.07, 95 %CI 1.00 - 1.15), fewer precut sphincterotomies (RR 0.75, 95 %CI 0.60 - 0.95), and no increase in other ERCP-related complications. Subgroup analyses indicated that this significant risk reduction in PEP with the guide wire-assisted cannulation technique existed only in "non-crossover" trials (RR 0.22, 95 %CI 0.12 - 0.42). The results were robust in sensitivity analyses. CONCLUSION Compared with the contrast-assisted cannulation technique, the guide wire-assisted cannulation technique increases the primary cannulation rate and reduces the risk of PEP, and therefore appears to be the most appropriate first-line cannulation technique.
Collapse
Affiliation(s)
- F Tse
- Division of Gastroenterology, McMaster University, Hamilton Health Sciences Centre, Hamilton, Ontario, Canada.
| | | | | | | |
Collapse
|
46
|
|
47
|
Tse F, Yuan Y, Moayyedi P, Leontiadis GI. Guidewire-assisted cannulation of the common bile duct for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Cochrane Database Syst Rev 2012; 12:CD009662. [PMID: 23235679 PMCID: PMC6885057 DOI: 10.1002/14651858.cd009662.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cannulation techniques have been recognized to be important in causing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, considerable controversy exists about the usefulness of the guidewire-assisted cannulation technique for the prevention of PEP. OBJECTIVES To systematically review evidence from randomised controlled trials (RCTs) assessing the effectiveness and safety of the guidewire-assisted cannulation technique compared to the conventional contrast-assisted cannulation technique for the prevention of PEP. SEARCH METHODS We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, and CINAHL databases and major conference proceedings, up to February 2012, using the Cochrane Upper Gastrointestinal and Pancreatic Diseases model with no language restrictions. SELECTION CRITERIA RCTs comparing the guidewire-assisted cannulation technique versus the contrast-assisted cannulation technique in patients undergoing ERCP. DATA COLLECTION AND ANALYSIS Two review authors conducted study selection, data extraction and methodological quality assessment independently. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi² test (P < 0.15) and I² statistic (> 25%). To explore sources of heterogeneity, we conducted a priori subgroup analyses according to trial design, publication type, risk of bias, use of precut sphincterotomy, inadvertent guidewire insertion or contrast injection of the pancreatic duct (PD), use of a PD stent, cannulation device, and trainee involvement in cannulation. To assess the robustness of our results we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed-effect versus random-effects), and per protocol analysis. MAIN RESULTS Twelve RCTs comprising 3450 participants were included. There was statistical heterogeneity among trials for the outcome of PEP (P = 0.04, I² = 45%). The guidewire-assisted cannulation technique significantly reduced PEP compared to the contrast-assisted cannulation technique (RR 0.51, 95% CI 0.32 to 0.82). In addition, the guidewire-assisted cannulation technique was associated with greater primary cannulation success (RR 1.07, 95% CI 1.00 to 1.15), less precut sphincterotomy (RR 0.75, 95% CI 0.60 to 0.95), and no increase in other ERCP-related complications. Subgroup analyses indicated that this significant risk reduction in PEP with the guidewire-assisted cannulation technique existed only in 'non-crossover' trials (RR 0.22, 95% CI 0.12 to 0.42). The results were robust in sensitivity analyses. AUTHORS' CONCLUSIONS Compared with the contrast-assisted cannulation technique, the guidewire-assisted cannulation technique increases the primary cannulation rate and reduces the risk of PEP, and it appears to be the most appropriate first-line cannulation technique.
Collapse
Affiliation(s)
- Frances Tse
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada.
| | | | | | | |
Collapse
|
48
|
Tse F, Yuan Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev 2012:CD009779. [PMID: 22592743 DOI: 10.1002/14651858.cd009779.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The role and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute gallstone pancreatitis remains controversial. A number of clinical trials and meta-analyses have provided conflicting evidence. OBJECTIVES To systematically review evidence from randomized controlled trials (RCTs) assessing the clinical effectiveness and safety of the early routine ERCP strategy compared to the early conservative management with or without selective use of ERCP strategy, based on all important, clinically relevant and standardized outcomes including mortality, local and systemic complications as defined by the Atlanta Classification (Bradley 1993) and by authors of the primary study, and ERCP-related complications in unselected patients with acute gallstone pancreatitis. SEARCH METHODS We searched the CENTRAL (The Cochrane Library), MEDLINE, EMBASE, and LILACS databases and major conference proceedings up to January 2012, using the Cochrane Upper Gastrointestinal and Pancreatic Diseases model with no language restrictions. SELECTION CRITERIA RCTs comparing the early routine ERCP strategy versus the early conservative management with or without selective use of ERCP strategy in patients with suspected acute gallstone pancreatitis. We included studies in which the population with acute gallstone pancreatitis was a subgroup within a larger group of patients. We only included studies involving only a selected subgroup of patients with acute gallstone pancreatitis (actual severe pancreatitis) in subgroup analyses. DATA COLLECTION AND ANALYSIS Two review authors conducted study selection, data extraction, and methodological quality assessment independently. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi² test and I² statistic. To explore sources of heterogeneity, we conducted a priori subgroup analyses according to predicted severity of pancreatitis, cholangitis, biliary obstruction, time to ERCP in routine ERCP strategy, use of selective ERCP in conservative management strategy, and risk of bias. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed versus random-effects), and per-protocol analysis. We performed influence analysis by exclusion of each study. MAIN RESULTS Five RCTs comprising 644 participants were included in the main analyses. Two additional RCTs, comprising only patients with actual severe acute gallstone pancreatitis, were included only in subgroup analyses. There was statistical heterogeneity among trials for mortality, but not for other outcomes. In unselected patients with acute gallstone pancreatitis, there were no statistically significant differences between the two strategies in mortality (RR 0.74, 95% CI 0.18 to 3.03), local and systemic complications as defined by the Atlanta Classification (RR 0.86, 95% CI 0.52 to 1.43; and RR 0.59, 95% CI 0.31 to 1.11 respectively) and by authors of the primary study (RR 0.80, 95% CI 0.51 to 1.26; and RR 0.76, 95% CI 0.53 to 1.09 respectively). The results were robust to sensitivity and influence analyses except for systemic complications as defined by the Atlanta Classification. There was no evidence to suggest that the results were dependent on predicted severity of pancreatitis. Among trials that included patients with cholangitis, the early routine ERCP strategy significantly reduced mortality (RR 0.20, 95% CI 0.06 to 0.68), local and systemic complications as defined by the Atlanta Classification (RR 0.45, 95% CI 0.20 to 0.99; and RR 0.37, 95% CI 0.18 to 0.78 respectively) and by authors of the primary study (RR 0.50, 95% CI 0.29 to 0.87; and RR 0.41, 95% CI 0.21 to 0.82 respectively). Among trials that included patients with biliary obstruction, the early routine ERCP strategy was associated with a significant reduction in local complications as defined by authors of the primary study (RR 0.54, 95% CI 0.32 to 0.91), and a non-significant trend towards reduction of local and systemic complications as defined by the Atlanta Classification (RR 0.53, 95% CI 0.26 to 1.07; and RR 0.56, 95% CI 0.30 to 1.02 respectively) and systemic complications as defined by authors of the primary study (RR 0.59, 95% CI 0.35 to 1.01). ERCP complications were infrequent. AUTHORS' CONCLUSIONS In patients with acute gallstone pancreatitis, there is no evidence that early routine ERCP significantly affects mortality, and local or systemic complications of pancreatitis, regardless of predicted severity. Our results, however, provide support for current recommendations that early ERCP should be considered in patients with co-existing cholangitis or biliary obstruction.
Collapse
Affiliation(s)
- Frances Tse
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada.
| | | |
Collapse
|
49
|
Tse F, Yuan Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009779] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
50
|
Tse F, Yuan Y, Moayyedi P, Leontiadis GI. Guidewire assisted cannulation of the common bile duct for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009662] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|