The association between sonographic common bile duct dilatation and outcomes in emergency department patients with cholangitis

BACKGROUND

The presentation of the patient with acute cholangitis (AC) ranges from mild illness to life-threatening shock. Therefore, prompt diagnosis and treatment are critical. Abdominal ultrasound (US) is the imaging of choice to locate bile duct dilatation. Other modalities include abdominal computed tomography (CT) or endoscopic retrograde cholangiopancreatography (ERCP).

OBJECTIVES

To determine whether sonographic common bile duct dilatation in emergency department (ED) patients with AC predicts outcomes including sepsis, hospital length of stay (LOS), admission to the intensive care unit (ICU), time to ERCP, and mortality.

METHODS

Electronic medical records of all patients hospitalized in a tertiary care medical center between July 2012-February 2021 with a discharge diagnosis of cholangitis were assessed. Patients were dichotomously classified as CBD dilated or CBD non-dilated based on ultrasound. Dilation was defined as CBD larger than 6 mm in patients younger than 60 or larger than 6 mm + 1 mm per decade in patients over 60.

RESULTS

The study included 271 patients- 172 with CBD dilation versus 99 without. Mean LOS was 9.92 days for those with a dilated CBD versus 13.4 days without. The mean time to ERCP was 4.26 days for those with a dilated CBD versus 6.56 days without. Sepsis, mortality, and ICU admission were scarce and there was no statistically significant difference between the cohorts.

CONCLUSION

Patients with a dilated CBD per the abdominal US performed during the patient's ED stay, underwent ERCP earlier, and were hospitalized fewer days than patients without CBD dilation.

Real-world experience with Curcumin-QingDai combination for patients with active ulcerative colitis: A retrospective multicentre cohort study

BACKGROUND

Curcumin and QingDai (QD, Indigo) have been shown to be effective for treating active ulcerative colitis (UC).

AIM

To evaluate the real-world experience with the Curcumin-QingDai (CurQD) herbal combination to induce remission in active UC.

METHODS

A retrospec-tive multicentre adult cohort study from five tertiary academic centres (2018-2022). Active UC was defined as a Simple Clinical Colitis Activity Index (SCCAI) ≥ 3. Patients were induced by CurQD. The primary outcome was clinical remission at weeks 8-12, defined as SCCAI ≤2 and a decrease ≥3 points from baseline. Secondary outcomes were clinical response (SCCAI decrease ≥3 points), corticosteroid-free remission, faecal calprotectin (FC) response (reduction ≥50%), FC normalisation (FC ≤100 μg/g for patients with FC ≥300 μg/g at baseline), and safety. All outcomes were analysed for patients who were maintaining stable treatment.

RESULTS

Eighty-eight patients were included; 50% were biologics/small molecules experienced, and 36.5% received ≥2 biologics/small molecules. Clinical remission was achieved in 41 (46.5%), and clinical response in 53 (60.2%). Median SCCAI decreased from 7 (IQR:5-9) to 2 (IQR:1-3); p < 0.0001. Of the 26 patients on corticosteroids at baseline, seven achieved corticosteroid-free remission. Among 43 biologics/small molecules experienced patients, clinical remission was achieved in 39.5% and clinical response in 58.1%. FC normalisation and response were achieved in 17/29 and 27/33, respectively. Median FC decreased from 1000 μg/g (IQR:392-2772) at baseline to 75 μg/g (IQR:12-136) at the end of inductions (n = 30 patients with paired samples); p < 0.0001. No overt safety signals emerged.

CONCLUSION

In this real-world cohort, CurQD effectively induced clinical and biomarker remission in patients with active UC, including patients who were biologics/small molecules experienced.

Inflammatory bowel disease in families with four or more affected first-degree relatives

BACKGROUND

Family history increases the risk for inflammatory bowel diseases (IBDs). However, data on differences in phenotypic characteristics among patients with a strong family history of IBD are scarce and controversial. The aim of the study was to compare the phenotypic features of IBD patients with four or more affected first-degree relatives with sporadic cases of IBD.

METHODS

Patients with familial and sporadic IBD were identified from the institutional IBD database. IBD patients from families with at least four first-degree affected relatives were selected for analysis and were compared to non-matched sporadic cases with IBD chosen randomly. Comparison for type of IBD (Crohn's disease (CD) vs. ulcerative colitis (UC)), age at onset as well as for disease extent, behavior, extraintestinal manifestations and indicators of severe disease were analyzed.

RESULTS

Thirty-five patients with familial IBD (28 CD, seven UC) were compared to 88 sporadic IBD patients (61 CD, 24 UC and three IBDU). Disease duration was 10.3 ± 8.2 in the familial and 8.0 ± 7.2 years in the sporadic cases, p=.13. The familial cases were younger at diagnosis (19.3 ± 8.6 vs. 25.7 ± 11.8, p=.004). Patients with familial compared to sporadic IBD were significantly more likely to require steroid treatment (80% vs. 54.5%, p=.009), biological treatment (94.3%, vs. 63.6%, p<.001) or surgery (25.7%, vs. 11.4%, p=.048).

CONCLUSIONS

IBD with a very strong positive family history is associated with younger age at onset and a more adverse IBD phenotype compared to sporadic IBD.

COVID-19 in Patients with Inflammatory Bowel Disease: The Israeli Experience

Background: Crohn’s disease (CD) and ulcerative colitis (UC) are chronic, immune-mediated inflammatory bowel diseases (IBD) affecting millions of people worldwide. IBD therapies, designed for continuous immune suppression, often render patients more susceptible to infections. The effect of the immune suppression on the risk of coronavirus disease-19 (COVID-19) is not fully determined yet. Objective: To describe COVID-19 characteristics and outcomes and to evaluate the association between IBD phenotypes, infection outcomes and immunomodulatory therapies. Methods: In this multi-center study, we prospectively followed IBD patients with proven COVID-19. De-identified data from medical charts were collected including age, gender, IBD type, IBD clinical activity, IBD treatments, comorbidities, symptoms and outcomes of COVID-19. A multivariable regression model was used to examine the effect of immunosuppressant drugs on the risk of infection by COVID-19 and the outcomes. Results: Of 144 IBD patients, 104 (72%) were CD and 40 (28%) were UC. Mean age was 32.2 ± 12.6 years. No mortalities were reported. In total, 94 patients (65.3%) received biologic therapy. Of them, 51 (54%) at escalated doses, 10 (11%) in combination with immunomodulators and 9 (10%) with concomitant corticosteroids. Disease location, behavior and activity did not correlate with the severity of COVID-19. Biologics as monotherapy or with immunomodulators or corticosteroids were not associated with more severe infection. On the contrary, patients receiving biologics had significantly milder infection course (p = 0.001) and were less likely to be hospitalized (p = 0.001). Treatment was postponed in 34.7% of patients until recovery from COVID-19, without consequent exacerbation. Conclusion: We did not witness aggravated COVID-19 outcomes in patients with IBD. Patients treated with biologics had a favorable outcome.

Short-term effectiveness and safety of tofacitinib in ulcerative colitis - real world data from tertiary medical centers in Israel

BACKGROUND

We sought to define the effectiveness and safety of tofacitinib in a real-world (RW) cohort of Israeli patients with moderate to severe ulcerative colitis (UC).

METHODS

This was a multi-center retrospective observational cohort study (2019-2020) to assess the effectiveness and safety of tofacitinib induction and maintenance therapy up to 26 weeks. Clinical response and remission were defined as a reduction in Simple Clinical Colitis Activity Index (SCCAI) or partial Mayo score (PMS) of ≥3 points, and SCCAI ≤2 or a PMS ≤1, respectively.

RESULTS

We included 73 patients, 47% male; median age 26 years [IQR: 19.5-39.5], disease duration 7 years [IQR: 2.5-14.5], follow-up 7.1 months [IQR: 3-12], 91% biologics-experienced, and 74% ≥ 2-biologics. Half of patients used concomitant corticosteroids (CS). Overall, 56.1% discontinued therapy due to either lack of response and/or adverse events (AEs), median time to discontinuation - 9.7 months [IQR 3.4-16]. Overall, response, remission, and CS-free-remission were achieved in 47.6%, 20.6%, and 17.5% of patients, respectively. At early maintenance (week 26), response, remission, and CS-free-remission were achieved in 65%, 22.5%, and 20% of patients, respectively. At week 26, tofacitinib 10 mg BID was still used in 43%. Seventeen patients (23.2%) had an adverse event including herpes zoster- 2.7%, hospitalization- 12.3%, and colectomy- 2.7%.

CONCLUSIONS

Tofacitinib was effective in achieving CS-free-remission in about 1/5 of highly biologics -experienced patients with UC. Despite a considerable proportion of patients maintained on tofacitinib 10 mg bid, it was well tolerated and safe. Earlier positioning of tofacitinib in the therapeutic algorithm may result in improved outcomes.

External kinesiology tape for improvement in fecal incontinence symptom bother in women: a pilot study

INTRODUCTION AND HYPOTHESIS

Fecal incontinence is a debilitating condition with a devastating impact on quality of life. Using a commercially available kinesiology band we developed an anal tape to be applied to the anus with the aim to determine its impact on symptom bother and quality of life.

METHODS

Four-week prospective, self-controlled, pilot study of patients with FI. The primary outcome was improvement in any of the four domains (lifestyle, coping/behavior, depression/self-perception, embarrassment) evaluated by the "Fecal Incontinence Quality of Life Scale." Secondary outcomes included improvement in frequency of incontinence events and safety. Days 0-14 served as control period and days 15-28 as study period. Patients were asked to rate their satisfaction and willingness to use the device in the future using a 10-cm continuous visual analog scale.

RESULTS

Twenty patients completed the study. Median age was 64 years; all patients were females. Significant improvements were observed in all domains of the Fecal Incontinence Quality of Life Scale from baseline to day 28 (p < 0.001 for all) and in three of four domains between day 15 and 28 (p < 0.04) but not between days 1 and 14. Five patients (25%) had a ≥ 50% improvement in incontinence events. Patients reported satisfaction and willingness to use the anal tape in the future. Other than mild difficulty to remove the anal tape, no adverse events were reported.

CONCLUSIONS

In this small pilot study, the use of the anal tape was safe and effective. The primary outcome of significant improvement in quality of life was achieved ( ClinicalTrials.gov ID:NCT02989545).

PUBLIC TRIAL REGISTRY

ClinicalTrials.gov identifier NCT02989545. https://clinicaltrials.gov/ct2/show/NCT02989545.

Anemia can predict the prognosis of colorectal cancer in the pre-operative stage: a retrospective analysis

BACKGROUND

Early detection of colorectal cancer (CRC) improves prognosis, yet many CRCs are diagnosed following symptoms. The aim of this study was to determine which CRC-related symptoms or signs can predict an advanced CRC in the pre-operative stage.

METHODS

Retrospective analysis of 300 patients who underwent surgery for CRC between the years 2008 and 2019. Patients' symptoms prior to CRC diagnosis were documented. Primary endpoint was the association of signs or/and symptoms with CRC diagnosis at TNM stages of 2-4 (i.e., highly advanced), compared to TNM score of 0-1 (i.e., locally advanced).

RESULTS

Three hundred patients, 91 with locally advanced and 209 with highly advanced CRC, were enrolled. There was a significant correlation between highly advanced CRC, compared to locally advanced, regarding tumor size (4.8 vs. 2.6 cm, p<0.001), presentation of any symptom prior to diagnosis (77% vs. 54%, p<0.001), anemia (46% vs. 29%, p=0.004), and severe anemia (17% vs. 4%, p=0.002). Mean hemoglobin was 12.2 ± 2.2 and 13.1 ± 1.8 in the highly advanced compared to locally advanced CRC, respectively, p<0.001. Anemia correlated with the T stage of the tumor: 21% of patients diagnosed at stages 0-1 had anemia, 39% at stage 2, 44% at stage 3, and 66% at stage 4 (p=0.001).

CONCLUSIONS

Anemia is the only finding that correlates with highly advanced CRC, in the pre-operative stage. When CRC has been diagnosed, the presence of anemia, at any level, may be considered in determining prognosis at the pre-operative stage. Physicians should be aware that when anemia is present, the risk for highly advanced CRC increases, and therefore should pursue with CRC detection.

High Failure Rate Following Restorative Surgery for Rectal Prolapse in Systemic Sclerosis Patients

INTRODUCTION

Systemic sclerosis (SSc) is a rare autoimmune connective tissue disorder. Colonic disorders are reported in 70% of patients. Only a few cases of rectal prolapse surgical repair in SSc patients were published, demonstrating high recurrence rate following any restorative surgery. The aim of this study is to present our surgical experience combined with the reported cases of SSc patients who underwent surgical interventions for rectal prolapse.

METHODS

We reviewed our data and the published reports in the English literature of patients with SSc who underwent surgery for rectal prolapse. We located 6 case reports, in addition to 3 patients who were operated in our center.

RESULTS

A total of 19 procedures (9 patients) were included, among them 17 restorative surgeries and 2 low anterior resections (LAR) with end-colostomy. All patients were female (mean age 70.3). Index surgery was perineal rectosigmoidectomy in 5, abdominal resection rectopexy in 3, and LAR with colostomy in 1 patient. All patients following restorative surgery suffered from fecal incontinence. 5 patients (62.5%) who underwent restorative surgery required at least 1 re-operation. The 2 patients who underwent LAR and colostomy reported a complete resolution of anorectal symptoms with a major improvement in their quality of life.

CONCLUSION

High recurrence rate is expected in SSc patients with rectal prolapse who undergo a restorative procedure. Low anterior resection and permanent colostomy provide an alternative surgical option to patients with SSc and prolapse in contrast to restorative surgery. We believe that this surgical approach should be offered for these patients.

Military Aviators with Inflammatory Bowel Diseases Continued Flying

INTRODUCTION: Military aviators are likely to be first diagnosed with inflammatory bowel diseases (IBD) during military service. Current recommendations support continuing flying with restrictions, but risks may be significant. The aim of the study was to document the long-term results of aviators newly diagnosed with IBD. METHODS: A prospective observational study over a 23-yr period included all Israeli Air Force (IAF) aviators with IBD. Primary end point was the qualification and safety to continue operational flying following IBD diagnosis. RESULTS: Subjects were 16 male aviators with an average follow-up of 130 mo. Average age was 27 (2045) and average time from symptoms onset to final diagnosis was 7.3 mo. Eight (50%) patients had Crohns disease (CD), and the other eight had ulcerative colitis (UC). Eight (50%) were high performance platform aviators. Two patients received biologic treatment, two were treated with repeated corticosteroid courses, and four with immunosuppressive therapy. Two patients underwent surgery and four needed different lengths of hospitalizations. Eight (50%) aviators (3 CD, 5 UC) were grounded for a mean of 177 d (5590). Altogether grounding for IBD aviators was 46/2087 mo (2.2%). Most grounding periods were short term and reversible. All aviators continued flying under annual monitoring or as needed and no compromise of their abilities was documented. CONCLUSIONS: All aviators were able to continue flying and no events of sudden incapacitation or severe disabling flares have been seen among patients. Our study findings support the current recommendation to continue flying when IBD is in stable remission. Tehori O, Koslowsky B, Gabbai D, Shapira S, Ben-Ari O. Military aviators with inflammatory bowel diseases continued flying. Aerosp Med Hum Perform. 2021; 92(10):831834.

Safety of oesophagogastroduodenoscopy in a nonagenarian population

BACKGROUND

invasive gastrointestinal (GI) procedures are increasingly performed on much older patients but data regarding oesophagogastroduodenoscopy (OGD) in this population are limited. We compared the indications, safety and benefits of OGD for nonagenarians compared to octogenarians.

METHODS

an observational retrospective review of patients who underwent OGD between 2013 and 2018 at a gastroenterology institute in one large hospital. Patients aged 90 and above 'nonagenarians' were compared to those aged 80-89 'octogenarians'.

RESULTS

472 patients (231 nonagenarians and 241 octogenarians), median age of 91 for nonagenarians (201 aged 90-94, 30 aged 95 and older) and 82 (174 aged 80-84, 67 aged 85-89) for octogenarians. GI bleeding was a more common and dyspepsia, a less common, indication for nonagenarians compared to octogenarians (55 and 7%, versus 43 and 18%). Significant findings and need for endoscopic treatments were both more commonly found in nonagenarians compared to octogenarians (25 and 24% versus 15 and 8%, respectively). General anaesthesia was more commonly given to nonagenarians (35 versus 10%). Immediate complications and 30-day mortality rate were similar between the groups: (2.6% of nonagenarians versus 1.6% of octogenarians). Of 30 patients aged 95 and older, 13% had late adverse events, compared to 1% of the overall cohort.

CONCLUSIONS

OGD appears safe in nonagenarians. Pathological findings and endoscopic interventions are more common. Decisions regarding OGD should not be based on age alone.

The pediatric ulcerative colitis activity index (PUCAI) predicts steroid-failure in adults with acute severe colitis

BACKGROUND

One-third of patients with acute severe ulcerative colitis (ASC) fail to respond to intravenous corticosteroids (IVCS) and require second-line therapy or colectomy. We aimed to explore the performance of the Pediatric Ulcerative Colitis Activity Index (PUCAI), for predicting response to IVCS in adults with ASC, and to base a two-step decision-making process for guiding the introduction of second-line therapy.

METHODS

This was a retrospective multicenter cohort study of adult patients with ASC. PUCAI score, Oxford criteria, and Swedish index were determined at baseline, day three and five of hospitalization, and discharge when outcomes were ascertained.

RESULTS

153 patients were included (mean age 34.7 ± 14.6, median disease duration 7.8 years [IQR 0-17.4]), of whom 51 (33%) required second-line therapy, and 23 (15%) eventually underwent colectomy by discharge. At days three and five, the median PUCAI scores were higher in non-responders compared with responders (55 [45-69] vs. 38 [25-55] at day 3, and 55 [36-65] vs. 20 [5-30] at day 5; both p < .001). The negative and positive predictive values (NPV and PPV) of IVCS failure were 76/63% for the Oxford criteria, 83/52% for the Swedish index as determined on day 3, and 73/100% for PUCAI ≥ 65 points on day five. The corresponding figures for PUCAI ≥ 45 at day 3 were 83/54%.

CONCLUSION

The PUCAI is a highly predictive tool for IVCS failure. PUCAI ≥ 45 on day 3 has an excellent NPV for IVCS failure indicating preparation for second-line therapy, and PUCAI ≥ 65 on day 5 has a high PPV to initiate the therapy.

Factors Associated with Inflammatory Bowel Disease Flare During Pregnancy Among Women with Preconception Remission

BACKGROUND

The factors associated with inflammatory bowel diseases (IBD) relapse throughout gestation in those with preconception remission remain unknown.

AIMS

We aimed to investigate disease and pregnancy course among IBD women with quiescent disease at conception.

METHODS

Women with IBD attending a multidisciplinary clinic for preconception, antenatal and postnatal treatment were prospectively recruited during 2011-2018.

RESULTS

Overall, 298 women with IBD with quiescent disease at the time of conception constituted the study cohort. Of these, 112 (37.6%) women experienced disease flare during pregnancy. The risk of disease relapse was higher in those with ulcerative colitis (UC) as compared to those with Crohn's disease (CD) (48.1% vs. 31.8%, P = 0.005). The proportion of women with prior IBD-related gastrointestinal surgery was lower in those who experienced disease flare up (13.4% vs. 26.3%, P = 0.009). The use of biologic therapy at the time of conception was associated with lower rates of disease relapse (25.0% vs. 43.9%, P = 0.001). In multivariate analysis, use of conventional medications or no treatment (aOR [95% CI]: 2.0 (1.12, 3.57), P = 0.02) and lack of prior history of IBD-related surgery (aOR [95% CI]: 3.13 (1.37, 7.14), P = 0.007) were independently positively associated with disease relapse. Rates of hospitalization during pregnancy (21.4% vs. 2.2%, P < 0.001) and preterm delivery (22.3% vs. 9.1%, P = 0.002) were higher, and birthweight was lower (median 2987 vs. 3153 grams, P = 0.05) in those with disease flare as compared to those who maintained remission.

CONCLUSION

Prior IBD-related surgery and biologic therapy were found as independent protective factors against relapse during pregnancy among women with quiescent disease at conception.

Gastroenterologists' Attitude Regarding Medical Cannabis for Inflammatory Bowel Diseases in Israel

BACKGROUND

The use of medical cannabis (MC) for inflammatory bowel diseases (IBDs) is expanding. Current evidence does not support the efficacy of MC for reducing inflammation in IBD patients. Even so, many gastroenterologists encounter the issue of recommending use of MC to IBD patients.

METHODS

A Web-based survey was completed by 84 (34%) gastroenterologists in Israel.

RESULTS

Out of 84 physicians whom completed the questionnaire, 59 (70%) were male, 34 (40%) were under age 50 years, 71 (85%) were adult gastroenterologists, and 53 (63%) work mainly in a hospital. Of them, 15, 41, and 44% of physicians think that MC is very effective, mildly effective, and not effective at all, respectively. Physicians will commonly, rarely, and never recommend MC in 31, 47, and 22%, respectively. Older physicians (above age 50 years) were significantly more likely to have a positive attitude towards MC in both questions. When presented with a clinical scenario of a patient in deep remission, requesting to increase the dose, 32% would increase, 49% would maintain, and only 18% would stop prescribing MC altogether; 48% of physicians did not know the recommended initial dose for MC. Only 2 (2.5%) physicians initiated the use of MC to all patients. Female gastroenterologists were significantly more likely to initiate MC, p = 0.048.

CONCLUSION

The use of MC for IBD patients is commonly encountered. Completely different attitudes regarding this treatment were seen. Age above 50 years and female physicians generally had a more positive attitude towards the use of MC. Guidelines and clear recommendations are needed.

Clinical utility of fecal calprotectin in monitoring disease activity and predicting relapse in pregnant patients with inflammatory bowel diseases

OBJECTIVES

Inflammatory bowel diseases (IBDs) are commonly diagnosed in reproductive-aged women and can substantially affect pregnancy outcomes. Non-invasive monitoring of IBD during the prenatal course is particularly challenging as traditional laboratory biomarkers are often affected by pregnancy-related physiologic changes. We aimed to evaluate the role of fecal calprotectin (FC) in monitoring disease activity and predicting relapse among IBD women throughout gestation.

METHODS

Women with IBD attending a multidisciplinary clinic for the preconception, antenatal and postnatal treatment were prospectively recruited during 2014-2018. FC levels were determined with an enzyme-linked immunoassay.

RESULTS

A total of 265 FC (preconception, n = 41; 1st trimester, n = 48; 2nd trimester, n = 84; 3rd trimester, n = 76; postpartum, n = 16) measurements were obtained in 157 pregnancies. Higher FC concentrations were found in all time points in those with active disease than those in remission as assessed by either physician global assessment or disease clinical scores. FC levels were significantly correlated with physician global assessment and disease activity indices in all 5 periods of investigation. Excluding those with disease flare at the time of conception, disease relapse was encountered during the prenatal course in 40 (31.5%) of the remaining 127 pregnancies. FC levels were significantly higher in those who experienced a disease flare later in the course of gestation as compared to those who maintained clinical remission (median 341 vs. 224 μg/g, P = 0.04).

CONCLUSION

FC appears to be a reliable marker of ongoing disease activity throughout the prenatal course as well as a predictor of imminent disease flare among IBD pregnant patients.

The severity of anemia does not correlate with the risk of gastrointestinal cancer in subsequent evaluation

Introduction: Iron deficiency anemia (IDA) is a risk factor for gastrointestinal (GI) malignancies. Little is known regarding the correlation between the depth of anemia and the risk for GI malignancy. The aim of this study was to test the hypothesis that very low hemoglobin levels pose an additional risk compared to low hemoglobin levels.Methods: Patients 40-70 years old, presenting to the ER with IDA during years 2016-2017 were retrospectively analyzed. Comparison was performed between two groups, one with a very low hemoglobin level (below 8 g/dL) and the other a low hemoglobin level (between 8-10 g/dL).Results: 1020 patients were analyzed, and 107 fulfilled the inclusion criteria. Seventy-five patients (70%) were in the very low hemoglobin group and 21 patients (19.6%) were diagnosed with a new GI malignancy. Mean age was 56, 49 (45%) were females, and 68 (63%) underwent esophagogastroduodenoscopy (EGD) or/and colonoscopy during the index hospitalization. The median hemoglobin and MCV were 7.3 G/dL, and 73 fL, respectively. New malignancies were found in 15/75 (20%) and 6/32 (19%) of patients with very low and low hemoglobin levels, respectively (p = .88). GI malignancies were more commonly found in females compared to males, 14 (29%) vs. 7 (12%), p = .032, respectively. The right colon was the most common site for malignancy. Active GI bleeding was not a risk factor for GI malignancy.Conclusions: Very low hemoglobin levels and overt GI bleeding do not pose an additional risk factor for GI malignancy, compared to low hemoglobin levels and no overt GI bleeding.

Disease flare at prior pregnancy and disease activity at conception are important determinants of disease relapse at subsequent pregnancy in women with inflammatory bowel diseases

PURPOSE

Disease flare throughout gestation are not uncommon among women with inflammatory bowel diseases (IBD), and can substantially affect pregnancy outcomes. We aimed to evaluate the effect of prior pregnancy outcome on the risk of disease flare at subsequent pregnancy in women with IBD.

METHODS

Women with IBD attending a multidisciplinary clinic for the preconception, antenatal and postnatal treatment were prospectively recruited during 2011-2018.

RESULTS

Overall, 476 IBD women were followed during the study period. Of them, 69 (14.5%) had two pregnancies throughout follow-up period and constituted the study cohort. Among these 69 women, 48 (69.6%) had Crohn's disease and 21 (30.4%) ulcerative colitis. The median interpregnancy interval was 20 [11-32] months. Overall, 34 (49.3%) women experienced disease flare at the subsequent pregnancy. In multivariate analysis, active disease at conception (odds ratio [95% CI]: 25.65 (3.05, 25.52), P < 0.001) and history of disease flare at the previous pregnancy (odds ratio [95% CI]: 4.21 (1.10, 16.58), P < 0.001) were the only independent predictors of disease relapse in current gestation. Rates of hospitalization during pregnancy (14.7% vs. 0, P = 0.02) and preterm delivery (32.4% vs. 5.7%, P = 0.006) were higher, and neonatal birth weight was lower (median 3039 vs. 3300 g, P = 0.03), in those with disease flare as compared to those with maintained remission.

CONCLUSION

History of disease relapse at previous gestation and periconception disease activity were found as important predictors of disease flare among IBD women. These data would facilitate adequate counseling and informed management decisions among reproductive-aged IBD women and their treating physicians.

Development and Validation of the IBD-REFER Criteria: Early Referral for Suspected Inflammatory Bowel Diseases in Adults and Children

Background

Early treatment of inflammatory bowel disease (IBD) is associated with positive outcomes but a significant diagnostic delay has been reported in most countries.

Aim

We aimed to develop and validate IBD-REFER criteria, intended for primary care physicians, to screen patients at risk for IBD.

Methods

A Delphi group of 10 experts generated a list of symptoms associated with the onset of IBD, supplemented by a review of the literature. The list was reduced in an iterative process and graded based on importance. For data-driven statistical formatting, the charts of 200 IBD (100 children, 100 adults) and 100 non-IBD controls but with gastrointestinal symptoms were reviewed. The IBD-REFER items were scored for each subject, as well as the contending Red Flag criteria from the International Organization for the Study of IBD. External validation was performed on additionally enrolled cohorts of 100 IBD patients and 50 controls.

Results

The Delphi process retained 5 items as major criteria (≥1 item required for early referral) and 11 as minor (≥2 items required). Following the removal of uninformative items and further formatting in the data-driven stage, 10 core items were retained: 3 as major and 7 as minor. In the external validation, the final IBD-REFER criteria had a sensitivity/specificity of 98%/96% in adults and 96%/96% in children, significantly higher than achieved by the Red Flag criteria (71%/84% and 60%/88%, respectively; P < 0.001).

Conclusion

The IBD-REFER criteria may guide the selection of patients for expedited gastrointestinal investigation.

Safety and effectiveness of ustekinumab for induction of remission in patients with Crohn's disease: A multicenter Israeli study

INTRODUCTION

Ustekinumab is an effective treatment of Crohn's disease (CD). Real-world data addressing the efficacy and safety of ustekinumab are scarce.

AIM

Our aim was to assess the safety and efficacy of ustekinumab in a large national patient cohort.

METHODS

A prospective multicenter study, in which we followed patients with active CD treated with ustekinumab for 24 weeks. Induction dose was intravenous ranging from 260 to 520 mg, according to body weight, followed by 90 mg doses given subcutaneously every 8 weeks. Clinical response was defined as a reduction of at least 1 severity category, as defined by Harvey-Bradshaw index (HBI). Patients with HBI < 5 were considered to be in clinical remission. Patients who stopped needing steroids at week 24 were defined as being in steroid-free clinical remission.

RESULTS

A total of 106 CD patients from eight Israeli centers were included. All patients were previously exposed to at least one biological agent. Our cohort consisted of 65 (61.3%) females. Mean age was 41 ± 14 years with an average disease duration of 12.2 ± 8 years. A total of 96 (90.5%) patients continued treatment throughout week 24. Clinical response was observed in 52% of these patients with mean HBI reduction from 8.34 ± 3.8 to 6.8 ± 4.4 at week 24 (p = 0.001). Clinical remission was achieved in 33 patients (31.1%). Moreover, the number of patients requiring steroid treatment was reduced by 66% at week 24. Out of 106 patients, 11 patients (10.4%) discontinued treatment: 3 due to adverse events (2.8%), 7 due to a lack of response, and 1 who was lost to follow-up. Following 24 weeks of treatment, 15 patients reported minor adverse events.

CONCLUSIONS

In a large real-world Israeli cohort of non-naïve-to-biological-treatment CD patients, ustekinumab was effective and safe in induction of clinical remission with a significant reduction in the number of patients requiring steroid treatment.

Ethnic Variations in Inflammatory Bowel Diseases Among Israel's Populations

BACKGROUND

Crohn's disease and ulcerative colitis are the two major classic presentations of inflammatory bowel diseases (IBD). Studies have shown a wide variation in the incidence and prevalence attributed to different geographic and ethnic populations.

OBJECTIVES

To assess the clinical characteristics of IBD among Arabs in Israel and to compare them to characteristics of IBD among Ashkenazi Jews.

METHODS

This retrospective, comparative study compared the clinical characteristics of IBD among 150 Arabs from the Holy Family Hospital and the Nazareth Hospital EMMS, both located in Nazareth, Israel, to those of 97 age- and sex-matched Ashkenazi Jewish patients from Shaare Zedek Medical Center, Jerusalem, Israel.

RESULTS

The Arab cohort, which included 106 patients (70%) with Crohn's disease and 44 (29%) with ulcerative colitis, was compared to 97 Ashkenazi patients (81% with Crohn's disease and 17% with ulcerative colitis) (P < 0.05). Alcohol consumption was found in both groups, but Arabs smoked more (46% vs. 12%, respectively, P < 0.05). Obstructive phenotype was lower in Arabs (10% vs. 32%, P < 0.05). 5-aminosalicylic acid and anti-tumor necrosis factor alpha were prescribed for the Arab and Ashkenazi groups (89% and 21%, respectively). The need for surgical intervention due to disease severity and/or complications was not significant (22% vs. 24%).

CONCLUSIONS

Despite similar reports of NOD2/CARD15 mutations, Crohn's disease is more common than ulcerative colitis within the Arab-Israeli population. Increased smoking rates may explain milder disease severities in Arabs, as reflected by lower obstructive pattern and frequent use of milder therapeutic modalities.

Sleep Disturbances Can Be Prospectively Observed in Patients with an Inactive Inflammatory Bowel Disease

BACKGROUND

Poor sleep quality is associated with adverse health consequences. Sleep disturbances can impact the immune function and inflammatory processes. Little is known about sleep disturbances in patients with inflammatory bowel disease (IBD), while not in flare, i.e., inactive.

AIMS

To prospectively explore the sleep quality of patients with an inactive IBD.

METHODS

This pilot study included 36 consecutive patients with IBD and 27 healthy volunteers. All IBD patients had an inactive disease. Participants underwent an overnight ambulatory polysomnography. Data on disease duration, medications, complications, and treatment were collected from the medical records.

RESULTS

The mean age of the IBD and the control groups was 39 ± 15 and 34.6 ± 9.6 years. A significantly less rapid eye movement (REM) sleep was noted in the IBD group vs. control (23.7 vs. 27.8%, p = 0.047); light sleep percentage and REM latency were also longer in the IBD group. Moreover, oxygen desaturation below 90% was more common in the IBD group. All other sleep parameters including respiratory disturbance index, apnea-hypopnea index, number of wakes, sleep latency, and snoring strength were similar in both groups.

CONCLUSIONS

Inactive IBD is associated with sleep disturbances. A larger prospective study should be conducted to confirm these findings.

Correction to: Antenatal Management for Women with Inflammatory Bowel Disease: Experience from Our 'IBD MOM' Clinic

The original version of the article unfortunately contained tagging error in first and family name of authors Ariella Bar-Gil Shitrit and Ami Ben Ya'acov. This has been corrected with this erratum.

Pregnancy-Onset Inflammatory Bowel Disease: A Subtle Diagnosis

BACKGROUND

Inflammatory bowel diseases (IBDs) are commonly diagnosed during the reproductive years. IBD first manifested during pregnancy (pregnancy-onset IBD [POIBD]) is still an undescribed entity. The aim of the study was to evaluate the characteristics and maternal and neonatal outcomes of patients with POIBD.

METHODS

Data of all pregnant women with IBD within a single multidisciplinary referral clinic, IBD-MOM, between 2011-2016, were analyzed. Maternal and neonatal characteristics and outcomes were compared between the POIBD group and those diagnosed before pregnancy (non-POIBD).

RESULTS

We identified 237 women, 31 (15%) from the POIBD group and 206 (85%) from the non-POIBD group. Eight (3.5%) patients experienced early spontaneous pregnancy loss, all in the non-POIBD group. The POIBD diagnosis occurred in 16 (52%) patients during the first trimester, 10 (32%) in second trimester, and 5 (16%) during third trimester. Diagnosis of ulcerative colitis (UC) was significantly more common in the POIBD group compared with the non-POIBD group (22/31, 71% vs 50/206, 24%, respectively, P < 0.001). More UC than Crohn's disease patients had active disease during pregnancy (69% vs 50%, P = 0.03, respectively). POIBD patients experienced vaginal delivery in 100% of births, compared with 164 (79.6%) in the non-POIBD group (P = 0.017). The mean gestational age at birth and the neonatal weight were similar among the study groups; 38.6 weeks and 3040 g for POIBD patients, compared with 38.7 weeks and 3055 g in the non-POIBD group.

CONCLUSIONS

POIBD is a unique clinical entity, and the diagnosis is mostly UC. However, the maternal and neonatal outcomes are similar.

Antenatal Management for Women with Inflammatory Bowel Disease: Experience from Our 'IBD MOM' Clinic

BACKGROUND

Inflammatory bowel disease affects women during their reproductive years and thus pregnancy outcomes. IBD MOM is a multidisciplinary, single-center clinic established to benefit women with IBD and their neonates.

AIM

The aim of this study was to evaluate the perinatal outcomes of the IBD MOM clinic patients compared to patients who attended antenatal and gastrointestinal disease community clinics (IBD CC).

METHODS

This single-center, prospective study was conducted from 2011 to 2015. The primary outcome was cesarean delivery; secondary was adverse perinatal outcomes. In parallel, a new pregnancy-oriented, disease severity score was evaluated for its association with perinatal risk (score low = 0 to severe = 5).

RESULTS

We identified 90 women in the IBD MOM clinic and 206 in the IBD CC. Maternal age, smoking habits, pregnancy complications, and type of IBD (CD/UC) were similar between groups. Rates of labor induction and birth weight were also similar between IBD MOM and IBD GI. The IBD MOM overall preterm delivery (PTD) rate (< 37 weeks) was significantly higher 18.9 versus 9.7% (P = 0.028). The IBD MOM group had a significantly higher IBD MOM disease severity score that correlated with a higher rate of PTD. The overall IBD MOM score and scores > 3 were significantly associated with PTD risk in both groups (P = 0.013 and P = 0.004, respectively).

CONCLUSION

Women with moderate and severe IBD who attended a multidisciplinary clinic may benefit from this unique center. Healthcare planning policies can assume that costly, multidisciplinary clinics for women with IBD should be reserved for those with moderate and severe disease.

Fecal Transplantation for Treatment of Clostridium Difficile Infection in Elderly and Debilitated Patients

BACKGROUND

Fecal microbiota transplantation (FMT) is a new technique recently introduced to treat recurrent Clostridium difficile infection (CDI). Little is known about the efficacy and risks of FMT in elderly and ill patients.

AIM

To investigate FMT efficacy in ill and elderly patients compared to conventional treatment.

METHODS

The study comprised two groups of patients between 2012 and 2016 with recurrent CDI at two medical centers in Israel. The study group received FMT and the controls conventional therapy. The primary end points were CDI recurrence, length of hospitalization, and short-term survival.

RESULTS

Thirty-four patients altogether, (21 females, mean age 82 years) participated, 11 received FMT and 23 controls. Demographics and clinical characteristics were similar between the two groups. Comorbidity indexes, i.e., Charlson index was high in both groups. In the FMT group, 10/11 (90%) patients showed clinical improvement 3 days after initiating treatment compared to 9/23 (39%) in the control group, p = 0.02. Survival at 2 months did not differ between the groups (FMT 54%, Control 50%, p = 0.816), but mean survival in the FMT group was higher than in the control (12 vs. 4 months, respectively, p = 0.015). Two significant adverse events from the FMT group included suspected aspirations, both occurring during gastroscopy route of administration.

CONCLUSIONS

FMT is effective for elderly and very ill patients. Safety is a concern, but is rare even in patients with much comorbidity. Colonoscopy may be the preferred route of FMT infusion.

A prospective study of fecal calprotectin and lactoferrin as predictors of small bowel Crohn's disease in patients undergoing capsule endoscopy

BACKGROUND

Capsule endoscopy (CE) is often used to investigate small bowel Crohn's disease (CD).

AIM

The aim of this study is to prospectively assess the value of fecal calprotectin and lactoferrin to predict CE findings.

PATIENTS AND METHODS

Sixty-eight consecutive patients that were referred for CE were included. Stool samples for calprotectin and lactoferrin and blood samples were collected for relevant parameters. Correlation between fecal markers and CE findings was assessed and receiver operating characteristic (ROC) curves were built to determine the predictive values of fecal markers for the diagnosis of CD.

RESULTS

Fecal calprotectin data was available for all the patients and lactoferrin data for 38. CE findings compatible with CD were found in 23 (33%) patients and 45 (67%) were negative for CD. The average age of the CD group was 34 compared to 46 in the non-CD group (p = .048). Median calprotectin and lactoferrin in the CD group and in the control group were 169 mg/kg vs. 40 (p = .004) and 6.6 mg/kg vs. 1 (p = .051), respectively. The area under the ROC curve was 0.767 for calprotectin and 0.70 for lactoferrin. A fecal calprotectin concentration of 95 mg/kg and fecal lactoferrin of 1.05 mg/kg had a sensitivity, specificity, positive predictive value and negative predictive value of 77 and 73%, 60 and 65%, 50 and 50%, and 84 and 84% in predicting CE findings compatible with CD.

CONCLUSIONS

Fecal markers are simple and noninvasive surrogates for predicting CE findings compatible with CD. Fecal markers can help determine which patients should be referred for CE. ClinicalTrials.gov Identifier: NCT01266629.

Is Needle Aspiration for Peritonsillar Abscess Still as Good as We Think? A Long-term Follow-up

Objective:

The aim was to study the therapeutic management, recurrence, and need for tonsillectomy in patients who underwent needle aspiration for peritonsillar abscess (PTA).

Methods:

A prospective observational design study was performed. Patients hospitalized in Shaare Zedek Medical Center between the years 2004 and 2007 with a diagnosis of PTA who underwent needle aspiration obtaining pus were included. A minimum 5-year follow-up was required for all patients. Recurrences, complications, the need for a repeated surgical procedure, length of hospital admission, and tonsillectomy were the primary end points.

Results:

The study included 117 patients. One hundred four patients (88.9%) improved after 1 needle aspiration without any other intervention, whereas 13 patients (11.1%) required an additional procedure. Broad spectrum antibiotics showed a statistical advantage over penicillin only, regarding need for recurrent procedure (14.7% vs 4.7%, P = .02). No short- or long-term complications were documented. Seventeen patients (14.5%) had any recurrence. Primary recurrent tonsillitis, female sex, and younger age were predictive risk factors for recurrent events of PTA (32% vs 10%, P < .01). A total of 18 patients (15.4%) eventually underwent tonsillectomy.

Conclusion:

Needle aspiration is an effective first line procedure for patients with PTA. Tonsillectomy is not necessary in most cases. In our study, young age, female sex, and recurrent tonsillitis are negative prognostic factors for recurrence. These patients should be managed accordingly. Broad spectrum antibiotics may offer additional advantages when compared to penicillin only.

Hearing Loss in Patients with Inflammatory Bowel Disease

Objectives:

Inflammatory bowel disease (IBD) has many characteristics of autoimmune diseases. Sensorineural hearing loss has been reported in many autoimmune diseases. Little is known about hearing loss in patients with IBD.

Methods:

A prospective blinded comparative study was conducted over a 3-year period. IBD patients and controls underwent a complete otolaryngology examination and audiometry test.

Results:

A total of 105 participants (76 patients and 29 controls) took part in this study. A total of 59 (77%) had Crohn’s disease (CD) and 17 (23%) had ulcerative colitis (UC). Mean age was 36 years, 51% were males and 40% of the patients were presently hospitalized due to IBD exacerbation. Sixteen of 76 (21%) of the IBD patients complained of hearing loss since first IBD diagnosis and 13% had current hearing disabilities. Audiometric examination revealed that any hearing loss (mild to severe) was found in 23 (30%) of the IBD population, compared with 3 (10%) of the control group ( P < .05). Sensorineural was the hearing deficiency type in 93% of them. Out of 46 patients, whose extraintestinal manifestation (EIM) status was clearly documented, 43% (n = 20) had EIMs. Hearing loss was present in 5 out of 20 (25%) of these patients, compared with 0 out of 23 who did not have EIMs ( P < .01). IBD phenotype, current hospitalization, and disease type were not different between these groups.

Conclusions:

Sensorineural hearing loss may be another EIM of IBD. It is found in 30% of IBD patients, and in up to 43% of patients with other EIMs. Early hearing evaluation should be recommended to IBD patients who have other EIMs.

Unexpected FDG-PET uptake in the gastrointestinal tract: Endoscopic and histopathological correlations

AIM: To investigate the nature and significance of unexpected positron emission tomography with fluorodeoxyglucose (FDG-PET) uptake within the gastrointestinal tract (GIT).

METHODS: Patients with unexpected FDG-PET findings in the GIT were evaluated. All patients had a previous confirmed malignancy, either solid or lymphoproliferative. The radiologic reports were performed by experienced radiologists with an exclusive PET expertise. Endoscopy, i.e., esophagogastroduodenoscopy (EGD) and colonoscopy, and histopathological evaluation of all findings was performed in all patients in accordance to the FDG-PET results. The findings from each of these modalities were compared to each other. Both clinically significant and insignificant findings were assessed.

RESULTS: Seventy-two patients were endoscopically evaluated. Twenty-seven patients (37.5%) had primarily a lymphoproliferative tumor and 45 (62.5%) had solid tumors. In 50 patients (69.4%) the endoscopic examination revealed lesions in the same anatomical areas as the FDG-PET findings. Among these 50 patients, malignant and premalignant lesions i.e., adenomatous polyps were found in 16 (32%) and 9 (18%) patients, respectively. Inflammation was noted in an additional 20 patients (40%). Compared to primary solid tumors, a background of primary lymphoproliferative malignancy was more likely to reveal an additional primary malignancy (15.6% vs 33.3%, respectively, P < 0.01). EGD compared to colonoscopy, revealed altogether 11 (25.6%) new malignancies compared to 5 (17.2%), respectively, P = 0.12. No GIT clinically significant findings were overseen by the FDG-PET.

CONCLUSION: Unexpected FDG uptake in the GIT is commonly encountered and may contain significant findings. Endoscopy evaluation is justified in order to detect these additional findings.

Normal vitamin D levels are associated with spontaneous hepatitis B surface antigen seroclearance

AIM: To investigate a possible association between serum vitamin D levels and spontaneous hepatitis B surface antigen (HBsAg) seroclearance.

METHODS: Fifty-three patients diagnosed with chronic inactive hepatitis B and spontaneous HBsAg seroclearance were followed up in two Israeli liver units between 2007 and 2012. This retrospective study reviewed medical charts of all the patients, extracting demographic, serological and vitamin D rates in the serum, as well as medical conditions and current medical therapy. Spontaneous HBsAg seroclearance was defined as the loss of serum HBsAg indefinitely. Vitamin D levels were compared to all patients who underwent spontaneous HBsAg seroclearance.

RESULTS: Out of the 53 patients who underwent hepatitis B antigen seroclearance, 44 patients (83%) had normal levels of 25-hydroxyvitamin vitamin D compared to 9 patients (17%) who had below normal levels. Multivariate analysis showed that age (> 35 years) OR = 1.7 (95%CI: 1.25-2.8, P = 0.05), serum vitamin D levels (> 20 ng/mL) OR = 2.6 (95%CI: 2.4-3.2, P = 0.02), hepatitis B e antigen negativity OR = 2.1 (95%CI: 2.2-3.1, P = 0.02), low viral load (hepatitis B virus DNA < 100 IU/mL) OR = 3 (95%CI: 2.6-4.2, P = 0.01) and duration of HBsAg seropositivity (> 8 years) OR = 1.6 (95%CI: 1.15-2.6, P = 0.04) were also associated with spontaneous HBsAg seroclearance.

CONCLUSION: We found a strong correlation between normal vitamin D levels and spontaneous HBsAg seroclearance.

Imported melioidosis, Israel, 2008

In 2008, melioidosis was diagnosed in an agricultural worker from Thailand in the southern Jordan Valley in Israel. He had newly diagnosed diabetes mellitus, fever, multiple abscesses, and osteomyelitis. Burkholderia pseudomallei was isolated from urine and blood. Four of 10 laboratory staff members exposed to the organism received chemoprophylaxis, 3 of whom had adverse events.

Detecting esophageal disease with second-generation capsule endoscopy: initial evaluation of the PillCam ESO 2

BACKGROUND AND STUDY AIM

Esophageal capsule endoscopy (ECE) provides an alternative, minimally invasive modality for evaluating the esophagus. This study evaluates the performance and test characteristics of a second-generation esophageal capsule endoscope, the PillCam ESO 2.

METHODS

Adults with known or suspected esophageal disease were included. Using the simplified ingestion procedure, each patient underwent capsule endoscopy with the PillCam ESO 2. Following ECE, esophagogastroduodenoscopy (EGD) was performed on the same day by an investigator who was blinded to the results of the ECE. In random order, capsule endoscopy videos were read and interpreted by the study investigator blinded to EGD results.

RESULTS

28 patients (19 men, 9 women; mean age 53.3 years) were included. In 82 % of the patients, at least 75 % of the Z line was visualized by the PillCam ESO 2. A per-lesion analysis demonstrated that the PillCam ESO 2 had definitive results in 30/43 lesions (69.8 %) and EGD in 29/43 (67.4 %), P value = 0.41. Compared with EGD for detecting suspected Barrett's esophagus and esophagitis, the PillCam ESO 2 had a sensitivity of 100 % and a specificity of 74 %, and a sensitivity of 80 % and a specificity of 87 %, respectively. The PillCam ESO 2 demonstrated 86 % agreement with EGD in describing the Z line (kappa statistic 0.68). The modified ingestion protocol provided excellent cleansing, with bubbles/saliva having no or only a minor effect on Z line images in 86 % of cases.

CONCLUSIONS

The PillCam ESO 2 demonstrated excellent visualization of the Z line. Compared with standard EGD, the PillCam ESO 2 had good test characteristics with high rates of detection of suspected Barrett's esophagus and esophagitis. This study provides indirect validation of the simplified ingestion procedure. The PillCam ESO 2 acquires high quality esophageal images, performs safely, and should be able to replace the current PillCam ESO.

Evaluation of the PillCam Colon capsule in the detection of colonic pathology: results of the first multicenter, prospective, comparative study

BACKGROUND AND STUDY AIMS

Population-based screening for colorectal cancer is widely recommended, with conventional colonoscopy considered to be the preferred diagnostic modality. However, compliance with screening colonoscopy is low and manpower capacity is limited. Capsule endoscopy might therefore represent a desirable alternative strategy.

PATIENTS AND METHODS

The PillCam Colon capsule endoscope was prospectively tested in a multicenter setting. The indications for endoscopy in the enrolled patients included colorectal cancer screening (43 %), postpolypectomy surveillance (26 %), and lower gastrointestinal signs and symptoms (31 %). Study subjects underwent colon preparation and then ingested the capsule on the morning of the examination, with conventional colonoscopy being performed the same day. The PillCam Colon capsule findings were reviewed by three experts in capsule endoscopy who were blinded to the conventional colonoscopy findings.

RESULTS

A total of 91 subjects were enrolled in three Israeli centers (55 men, 36 women; mean age 57), and the results were evaluable in 84 cases. The capsule was excreted within 10 hours in 74 % of the patients and reached the rectosigmoid colon in the other 16 %. Of the 84 evaluable patients, 20 (24 %) had significant findings, defined as at least one polyp of 6 mm or more in size or three or more polyps of any size: 14/20 (70 %) were identified with the capsule and 16/20 (80 %) were identified by conventional colonoscopy. Polyps of any size were found in 45 patients, 34/45 (76 %) found by the capsule and 36/45 (80 %) by conventional colonoscopy. In comparison with conventional colonoscopy, false-positive findings on PillCam Colon capsule examination were recorded in 15/45 cases (33 %). There were no adverse events related to the capsule endoscopy.

CONCLUSIONS

PillCam Colon capsule endoscopy appears to be a promising new modality for colonic evaluation. Further improvements in the procedure will probably increase capsule examination completion and polyp detection rates. Additional studies are needed to evaluate the accuracy of PillCam Colon endoscopy in other patient populations with different prevalence levels of colonic disease.

PillCam ESO in esophageal studies: improved diagnostic yield of 14 frames per second (fps) compared with 4 fps

BACKGROUND AND STUDY AIM

Capsule endoscopy, using the PillCam ESO and sending images at a rate of 4 frames per second (fps), has a high sensitivity and specificity in diagnosing gastroesophageal reflux disease (GERD) lesions. We tested a new device which produces images at a rate of 14 fps. The diagnostic performance and esophageal visualization of these two devices were compared.

PATIENTS AND METHODS

42 patients with GERD symptoms and eight patients with a history of Barrett's esophagus had an esophagogastroduodenoscopy (EGD). All patients underwent capsule endoscopy of the esophagus within 1 hour prior to EGD. The first 25 patients had a capsule endoscopy examination with the 4-fps device. The following 25 patients underwent capsule endoscopy under identical conditions but using the 14-fps device. The reader of the capsule endoscopy study was blinded to the EGD findings. A diagnosis of GERD or Barrett's esophagus was established with EGD. The findings at capsule endoscopy were compared with the EGD findings. We also examined how frequently the esophagus in its entirety was visualized by these two devices.

RESULTS

The 4-fps device diagnosed 16/19 cases of esophageal erosions or ulcers (sensitivity 84 %) and 6/8 cases of Barrett's esophagus (sensitivity 75 %). The 14-fps capsule diagnosed 16/16 cases of esophageal ulcers or erosions and 7/7 cases of Barrett's esophagus (sensitivity 100 %). The total diagnostic miss rate in the 4-fps group was 5/27 (18 %) whereas the diagnostic miss rate in the 14-fps group was 0/23 (0 %) P < 0.02). The upper esophageal sphincter (UES) was clearly identified in 6/25 patients (24 %) in the 4-fps group and in 20/25 patients (80 %) in the 14-fps group ( P < 0.01). The entire esophagus was well visualized in 3/25 patients (12 %) by the 4-fps device and in 19/25 (76 %) by the 14-fps device ( P < 0.01). The superiority of the 14-fps PillCam ESO capsule is consistent with the data obtained from fluoroscopic studies of swallowed PillCam capsules, showing that capsule speed may reach 20 cm/s. For the 14-fps PillCam this means one image transmitted per 3-cm segment at maximal capsule speed, therefore still allowing for full visualization of the entire esophagus.

CONCLUSIONS

Capsule endoscopy using the 14-fps PillCam ESO showed a greater sensitivity than that of the 4-fps device for identifying GERD. The 14-fps PillCam ESO was statistically superior to the 4-fps device in visualizing the opening of the UES and the entirety of the esophagus.