Milan Ultrasound Criteria Predict Relapse of Ulcerative Colitis in Remission

Introduction

Bowel ultrasound is a noninvasive alternative to endoscopy for assessing the disease activity of ulcerative colitis; however, it is unclear whether bowel ultrasound can predict subsequent relapse from remission.

Materials and Methods

A retrospective cohort study enrolled patients with ulcerative colitis who underwent bowel ultrasound between July 2018 and July 2021 during clinical remission (patient-reported outcome-2 ≤1 and no rectal bleeding) for at least 3 months and were followed up for 1 year. Ultrasonographic findings (bowel wall thickness, bowel wall flow, bowel wall stratification, and enlarged lymph nodes), Milan ultrasound criteria, Mayo endoscopic subscore, C-reactive protein, and fecal calprotectin levels and their association with subsequent clinical relapse were assessed. Relapse was defined as rectal bleeding score ≥1, stool frequency score ≥2, or treatment intensification for symptoms.

Results

31% of the patients (18/58) relapsed within 1 year. No single ultrasonographic finding predicted relapse, whereas Milan ultrasound criteria >6.2 (p = 0.019), Mayo endoscopic subscore ≥1 (p = 0.013), and fecal calprotectin ≥250 μg/g (p = 0.040) were associated with a shorter time to relapse in the log-rank test. Milan ultrasound criteria >6.2 (hazard ratio 3.22; 95% confidence interval 1.14-9.08, p = 0.027) and Mayo endoscopic subscore ≥1 (hazard ratio 8.70; 95% confidence interval 1.11-68.1, p = 0.039) showed a higher risk of relapse according to a Cox proportional hazards model.

Conclusion

Bowel ultrasound can predict subsequent clinical relapse from remission in patients with ulcerative colitis using the Milan ultrasound criteria.

A Novel Hemostatic Peptide Solution for Common Acute Gastrointestinal Bleeding Diseases: First Case Series Study on the Treatment Results of Endoscopic Hemostasis by Nonexpert Endoscopists

INTRODUCTION

We investigated the hemostatic effect and safety of a hemostatic peptide solution for the treatment of gastrointestinal bleeding requiring emergency endoscopy.

METHODS

We retrospectively examined the patient backgrounds, hemostatic results, and procedural safety in patients who were treated with a hemostatic peptide solution for hemostasis during emergency endoscopies for gastrointestinal bleeding. All hemostatic procedures were performed by nonexpert physicians with less than 10 years of endoscopic experience. All of the cases were treated at a single institution over the months from January 2022 to January 2023.

RESULTS

Twenty-six consecutive patients (17 males and 9 females) with a median age of 74 (45-95) years were included. Their conditions requiring emergency endoscopy were melena in 8 patients, hematochezia in 2, hematemesis in 8, anemia in 6, and bleeding during esophagogastroduodenoscopy in 2. The sites of bleeding were the esophagus in 3 patients, the stomach in 17, the duodenum in 3, the small intestine in 2, and the colon in 1. Hemostasis was obtained with another hemostasis device used in conjunction with the hemostatic peptide solution in 13 cases and with the hemostatic peptide solution alone in 13 cases. The hemostasis success rate was 100%, with no complications. Rebleeding occurred within 1 week in 4 cases.

CONCLUSION

Hemostasis with the hemostatic peptide solution was safe and provided a temporary high hemostatic effect in emergency gastrointestinal endoscopy.

Letter: Transperineal ultrasonography for ulcerative proctitis-Applicability in the pregnant population? Authors' reply

This article is linked to Sagami et al papers. To view these articles, visit https://doi.org/10.1111/apt.16817 and https://doi.org/10.1111/apt.17669

Multiple ulcerative colitis-associated aseptic abscesses successfully treated with infliximab: a case report

Aseptic abscesses are rare extraintestinal manifestations of inflammatory bowel disease. Herein, we present the case of a 69-year-old female patient with ulcerative colitis in whom multiple aseptic abscesses were successfully treated with infliximab. Aseptic abscesses associated with ulcerative colitis are difficult to differentiate from infectious abscesses. In the present case, we reached a diagnosis of aseptic abscesses associated with ulcerative colitis as antibiotics were ineffective and repeated Gram stains and cultures of blood and abscess were negative. Aseptic abscesses are commonly found in the spleen, lymph nodes, liver, and skin; however, in the present case, the periosteum was the major site. Prednisolone is often effective for aseptic abscesses; however, the present patient was initially treated with a combination of 40 mg/day of prednisolone and granulocyte and monocyte adsorption apheresis, with inadequate effect. Infliximab was administered as the patient was steroid-resistant, with strong effect. Subsequently, infliximab treatment has been continued, with no recurrence after 2 years. However, as there have been reports of cases of recurrence even after remission with treatment, careful follow-up in the future is therefore necessary.

Optimal Use of Serum Leucine-Rich Alpha-2 Glycoprotein as a Biomarker for Small Bowel Lesions of Crohn's Disease

Introduction

A large proportion of small bowel lesions in Crohn's disease (CD) may exist beyond the reach of ileocolonoscopy and there is no gold standard imaging modality to screen them, suggesting the need for optimal biomarkers. We aimed to compare the usefulness of C-reactive protein (CRP), faecal calprotectin (FC), and leucine-rich alpha-2 glycoprotein (LRG) in determining small bowel lesions of CD.

Methods

This was a cross-sectional observational study. CRP, FC, and LRG were prospectively measured in patients with quiescent CD who underwent imaging examinations (capsule or balloon-assisted endoscopy, magnetic resonance enterography, or intestinal ultrasound) selected by the physician in clinical practice. Mucosal healing (MH) of the small bowel was defined as a lack of ulcers. Patients with a CD activity index >150 and active colonic lesions were excluded.

Results

A total of 65 patients (27, MH; 38, small bowel inflammation) were analysed. The area under the curve (AUC) of CRP, FC, and LRG was 0.74 (95% confidence interval: 0.61-0.87), 0.69 (0.52-0.81), and 0.77 (0.59-0.85), respectively. The AUC of FC and LRG in a subgroup of 61 patients with CRP <3 mg/L (26, MH; 32, small bowel inflammation) was 0.68 (0.50-0.81) and 0.74 (0.54-0.84), respectively. The cut-off of 16 μg/mL of LRG showed the highest positive predictive value of 1.00 with specificity of 1.00, while negative predictive value was highest (0.71) with sensitivity of 0.89 at the cut-off of 9 μg/mL.

Conclusion

LRG can accurately detect and/or exclude the small bowel lesions with two cut-off values.

Usefulness of colestimide for diarrhea in postoperative Crohn's disease

Background and Aim

Crohn's disease (CD) often causes intractable diarrhea after intestinal resection. Anion exchange resins have been reported to be effective in patients with bile acid diarrhea after distal ileectomy; furthermore, bile acid metabolism has been implicated in the pathogenesis of CD. Therefore, we aimed to examine the effectiveness of colestimide in the management of postoperative CD, and to compare its impact between patients with and those without ileocecal resection.

Methods

Postoperative CD patients prescribed colestimide for diarrhea between April 2017 and December 2020 were retrospectively evaluated for changes in the total Crohn's disease activity index (CDAI), each CDAI component including diarrhea frequency/week, albumin, and C‐reactive protein (CRP) was evaluated before and after the administration of colestimide. Furthermore, comprehensive patient and physician assessments were reviewed from medical records during the first outpatient visit as a global clinical judgment after the initiation of colestimide therapy.

Results

A total of 24 patients were included, of whom 17 had a previous history of ileocecal resection. Significant improvement was noted in CDAI and diarrhea frequency only in the ileocecal resection group (CDAI: 114.5 ± 52.7 and 95.4 ± 34.8, P < 0.05; diarrhea frequency/week 23.8 ± 14.1 and 15.4 ± 11.2, P < 0.05, respectively). There was no significant improvement in other CDAI components, albumin level, or CRP level in either group. In the global clinical judgment, 13 and 4 patients in the ileocecal and non‐ileocecal resection groups, respectively, were judged as “effective,” with an overall efficacy rate of 70.8%.

Conclusion

Colestimide is effective for diarrhea in patients with postoperative CD, especially after ileocecal resection.

[Thrombectomy for right atrial thrombosis complicating a pyogenic liver abscess]

Vascular complications from a liver abscess are rare but life-threatening. Herein, we report the case of a man in his 40s with a pyogenic hepatic abscess complicated by an inferior vena caval thrombus extending to the right atrium. His presenting complaint was a high fever. Blood tests revealed elevated inflammatory markers and liver enzymes. An abdominal CT demonstrated a 10cm abscess in the right hepatic lobe. A blood culture grew Streptococcus intermedius, which was sensitive to ampicillin sulbactam. He was diagnosed with a pyogenic liver abscess and treated with metronidazole and ampicillin sulbactam. Three days following admission, an abdominal CT scan revealed the thrombus extending from the liver abscess into the right atrium. He underwent thrombectomy and received antibiotic therapy. Postoperatively, abdominal ultrasound revealed a significant decrease in the size of the hepatic abscess. The patient was discharged in good condition on the 46th day of hospitalization. When encountering a hepatic abscess, it is important to consider that it may be associated with a thrombus extending from the inferior vena cava into right atrium.

One-year follow up after admission to an emergency department for drug overdose in Japan

AIM

The aim of the study was to investigate the incidence of and risk factors for repetition of suicidal behavior within a year after admission for drug overdose in Japan.

METHODS

Patients admitted to the emergency department of a general public hospital in Tokyo for drug overdose of prescribed medicine and/or over-the-counter drugs between March 2008 and February 2009 were followed up after 1 year. Demographic characteristics, previous suicide attempts, and mental health state were examined by self-report questionnaire and interview at recovery from the initial attempt. Information about suicidal behavior during the follow-up period was obtained from the outpatient psychiatrists by postal questionnaire 1 year after discharge.

RESULTS

Of 190 patients admitted to the emergency department, 132 patients answered the questionnaire and had the interview. Information about thefollow-up period for 66 patients was obtained. Of the 66 patients, 28 patients attempted suicide again and two patients committed suicide during the 1-year follow-up period. Psychiatric diagnosis of personality disorder and denial of suicidal intent at the time of recovery were associated with increased risk for another suicide attempt. Lethality levels of suicidal behaviors before and after admission were associated with each other.

CONCLUSION

The rate of fatal and non-fatal suicide attempt within a year after admission for self-poisoning was substantial. Psychiatric diagnosis of personality disorder was a risk factor for repetition of suicide attempt. Clinicians should pay attention to the means of previous suicide attempts even though the patient denies suicidal intent at recovery.

Gamma knife radiosurgery for growth hormone-secreting pituitary adenomas invading the cavernous sinus

The authors assessed whether gamma knife radiosurgery is effective for patients with acromegaly where the pituitary tumors invaded the cavernous sinus. Radiosurgery was performed on 9 patients (average of 20 Gy to the tumor margin), 8 of whom had already undergone transsphenoidal surgery and/or craniotomy with occasional medication of octreotide to reduce tumor size as well as hormonal levels. All tumors have been well controlled so far with follow-up periods ranging from 12 to 69 months (mean: 42). No complications occurred. Forty percent of the patients showed hormonal normalization at 2 years, with the median being 31 months. Similarly, 50% of the patients demonstrated normalization of GH and IGF-I at 36 months. We conclude that gamma knife radiosurgery is a safe and effective tool to treat these tumors invading the cavernous sinus.

Cavernous sinus hemangioma treated with gamma knife radiosurgery: usefulness of SPECT for diagnosis--case report

A 79-year-old female presented with cavernous sinus hemangioma manifesting as double vision due to right oculomotor and trochlear nerve pareses. Computed tomography and magnetic resonance imaging revealed bony erosion and a right cavernous sinus tumor with "tail sign" after contrast medium administration. Thallium-201 (201Tl) single photon emission computed tomography (SPECT) showed low uptake within the tumor, and technetium-99m-human serum albumin-diethylenetriaminepenta-acetic acid SPECT disclosed high uptake within the tumor. 201Tl SPECT usually shows very high uptake in meningiomas and malignant tumors, so the tumor was considered to be an unrelated benign tumor. The patient underwent partial resection of the tumor. Histological examination of the specimen confirmed cavernous hemangioma. The oculomotor nerve paresis partially improved. Gamma knife radiosurgery was carried out 4 months after the operation. The tumor markedly shrank with full recovery of extraocular movement 6 months after radiosurgery. SPECT is useful for distinguishing cavernous sinus hemangiomas from other cavernous tumors. Radiosurgery should be performed after partial resection or biopsy for cavernous sinus hemangiomas and may be the initial treatment for patients with small cavernous sinus hemangioma if the diagnosis can be established based on neuroimaging.