398. Post-Infectious Irritable Bowel Syndrome in Patients Referred to a Complicated Clostridioides difficile Clinic

Background

Recurrence of Clostridioides difficile infection (CDI) occurs in up to 20-30% after an initial episode and up to more than half of patients with previous infection. C. difficile has also been associated with post-infectious irritable bowel syndrome (PI-IBS) following the resolution of an acute infection, complicating assessment of gastrointestinal symptoms post-CDI. The prevalence and risk factors for post-CDI IBS are not as well-defined as PI-IBS secondary to other pathogens.

Methods

In this study, we examined the electronic medical record of 67 consecutive patients referred to a Complicated C. Difficile Clinic from March 2020 to July 2021 for consideration of fecal microbiota transplantation.

Results

Patients were referred by primary care providers (54%), gastroenterologists (16%), hospital admitting team (19%) or others (10%). Mean age was 64 (21-93) and 51 patients (76%) were female. In 25 out of the 67 patients (37%), treatment was prescribed without documentation of a positive C. difficile assay. We found that 32.8% of patients referred to the clinic for recurrent CDI had symptoms consistent with post-CDI IBS. Patients with post-CDI IBS were generally younger in age (P = 0.03), had fewer medical comorbidities (P = < 0.001), and more often had history of anxiety (P = 0.03) than patients with a diagnosis of CDI.

Conclusion

Our findings suggest that post-CDI IBS is prevalent, can be misdiagnosed as CDI recurrence, and may lead to inappropriate use of anti-C. difficile agents or interventions.

Disclosures

All Authors: No reported disclosures.

Inherent Immune Cell Variation Within Colonic Segments Presents Challenges for Clinical Trial Design

BACKGROUND AND AIMS

Intestinal biopsy sampling during IBD trials represents a valuable adjunct strategy for understanding drug responses at the tissue level. Given the length and distinctive embryonic origins of the proximal and distal colon, we investigated whether inherent regional differences of immune cell composition could introduce confounders when sampling different disease stages, or pre/post drug administration. Here, we capitalise on novel mass cytometry technology to perform deep immunophenotyping of distinct healthy colonic segments, using the limited numbers of biopsies that can be harvested from patients.

METHODS

Biopsies [2.8 mm] were collected from the caecum, transverse colon, descending colon, and rectum of normal volunteers. Intestinal leukocytes were isolated, stained with a panel of 37 antibodies, and mass cytometry data acquired.

RESULTS

Site-specific patterns of leukocyte localisation were observed. The proximal colon featured increased CD8+ T cells [particularly resident memory], monocytes, and CD19+ B cells. Conversely, the distal colon and rectum tissues exhibited enrichment for CD4+ T cells and antibody-secreting cells. The transverse colon displayed increased abundance of both γδ T cells and NK cells. Subsets of leukocyte lineages also displayed gradients of expression along the colon length.

CONCLUSIONS

Our results show an inherent regional immune cell variation within colonic segments, indicating that regional mucosal signatures must be considered when assessing disease stages or the prospective effects of trial drugs on leukocyte subsets. Precise protocols for intestinal sampling must be implemented to allow for the proper interpretation of potential differences observed within leukocyte lineages present in the colonic lamina propria.

Accelerated infliximab infusions for inflammatory bowel disease improve effectiveness

AIM: To study the safety and effectiveness associated with accelerated infliximab infusion protocols in patients with inflammatory bowel disease (IBD).

METHODS: Original protocols and infusion rates were developed for the administration of infliximab over 90-min and 60-min. Then the IBD patients on stable maintenance infliximab therapy were offered accelerated infusions. To be eligible for the study, patients needed a minimum of four prior infusions. An initial infusion of 90-min was given to each patient; those tolerating the accelerated infusion were transitioned to a 60-min infusion protocol at their next and all subsequent visits. Any patient having significant infusion reactions would be reverted to the standard 120-min protocol. A change in a patient’s dose mandated a single 120-min infusion before accelerated infusions could be administered again.

RESULTS: The University of Virginia Medical Center's Institutional Review Board approved this study. Fifty IBD patients treated with infliximab 5 mg/kg, 7.5 mg/kg and 10 mg/kg were offered accelerated infusions. Forty-six patients consented to participate in the study. Nineteen (41.3%) were female, five (10.9%) were African American and nine (19.6%) had ulcerative colitis. The mean age was 42.6 years old. Patients under age 18 were excluded. Ten patients used immunosuppressive drugs concurrently out of which six were taking azathioprine, three were taking 6-mercaptopurine and one was taking methotrexate. One of the 46 study patients used corticosteroid therapy for his IBD. Seventeen of the patients used prophylactic medications prior to receiving infusions; six patients received corticosteroids as pre-medication. Four patients had a history of distant transfusion reactions to infliximab. These reactions included shortness of breath, chest tightness, flushing, pruritus and urticaria. These patients all took prophylactic medications before receiving infusions. 46 patients (27 males and 19 females) received a total of fifty 90-min infusions and ninety-three 60-min infusions. No infusion reactions were reported. There were no adverse events, including drug-related infections. None of the patients developed cancer of any type during the study timeframe. Total cost savings for administration of the both 90-min and 60-min accelerated infusions compared to standard 120-min infusions was estimated to be $53 632 ($116 965 vs $63 333, P = 0.001). One hundred and eighteen hours were saved in the administration of the accelerated infusions (17 160 min vs 10 080 min, P = 0.001). In the study population, overweight females [body mass index (BMI) > 25.00 kg/m²] were found to have statistically higher BMIs than overweight males (mean BMI 35.07 ± 2.66 kg/m²vs 30.08 ± 0.99 kg/m², P = 0.05), finding which is of significance since obesity was described as being one of the risk factors for Crohn’s disease.

CONCLUSION: We are the first US group to report substantial cost savings, increased safety and patient satisfaction associated with accelerated infliximab infusion.

Skin signs in diabetes mellitus

Diabetes mellitus is the most common endocrine disorder with continuously increasing prevalence. Blood vessels, nerves, eyes, kidneys and skin are affected, which causes both an enormous financial burden and a reduced quality of life of the affected patients. Long-standing diabetes may impair skin homeostasis resulting in skin manifestations in at least one third of all diabetics. The skin involvement may be the first presenting sign of diabetes, thus the respective skin signs should lead to diabetes focused diagnostic. Besides, the skin signs may be considered as a marker for the course of the disease or for the success of therapeutic interventions.

Cytokines, chemokines and growth factors in wound healing

In wound healing, a variety of mediators have been identified throughout the years. The mediators discussed here comprise growth factors, cytokines and chemokines. These mediators act via multiple (specific) receptors to facilitate wound closure. As research in the last years has led to many new findings, there is a need to give an overview on what is known, and on what might possibly play a role as a molecular target for future wound therapy. This review aims to keep the reader up to date with selected important and novel findings regarding growth factors, cytokines and chemokines in wound healing.

Partially covered self-expandable metallic stents for benign biliary strictures due to chronic pancreatitis

BACKGROUND AND STUDY AIMS

Benign biliary strictures (BBS) may occur in patients with chronic pancreatitis and may lead to secondary biliary cirrhosis or recurrent cholangitis. Although surgical diversion may provide definitive therapy, it can be associated with significant morbidity. Endoscopic therapy with plastic stents has been used as an alternative to surgery but has resulted in unsatisfactory long-term outcomes. We evaluated the temporary placement of partially covered self-expandable metallic stents (PCMS) in patients with BBS due to chronic pancreatitis.

PATIENTS AND METHODS

A total of 20 patients with BBS due to chronic pancreatitis underwent temporary placement of PCMS over a 6-year period. The primary outcome of interest was the proportion of patients with stricture resolution persisting 6 months after stent removal. Secondary outcomes included the stent failure rate, number of endoscopic sessions required to achieve biliary drainage, total duration of stenting, and complication rate.

RESULTS

Adequate biliary drainage was achieved in 19 patients with PCMS (95%). Eighteen of the 20 patients (90%) had persistent stricture resolution 6 months after PCMS removal. In two of the 20 patients (10%), PCMS stenting failed and these patients underwent alternative therapies. Complications occurred in four patients (20%). Median duration of PCMS placement was 5 months, requiring a median of two endoscopic procedures.

CONCLUSION

In this series of patients with BBS due to chronic pancreatitis, temporary PCMS placement achieved persistent stricture resolution in the majority of patients with acceptable complication rates. Comparative trials evaluating temporary PCMS placement and plastic stenting in patients with BBS due to chronic pancreatitis are needed.

Temporary placement of covered self-expandable metal stents in benign biliary strictures: a new paradigm? (with video)

BACKGROUND

Benign biliary strictures (BBS) are usually managed with plastic stents, whereas placement of uncovered metallic stents has been associated with failure related to mucosal hyperplasia.

OBJECTIVE

We analyzed the efficacy and safety of temporary placement of a covered self-expanding metal stent (CSEMS) in BBS.

DESIGN

Patients with BBS received temporary placement of CSEMSs until adequate drainage was achieved; confirmed by resolution of symptoms, normalization of liver function tests, and imaging.

SETTING

Tertiary-care center with long-standing experience with CSEMSs.

PATIENTS

Seventy-nine patients with BBS secondary to chronic pancreatitis (32), calculi (24), liver transplant (16), postoperative biliary repair (3), autoimmune pancreatitis (3), and primary sclerosing cholangitis (1).

INTERVENTION

ERCP with temporary CSEMS placement. Removal of CSEMSs was performed with a snare or a rat-tooth forceps.

MAIN OUTCOME MEASUREMENTS

End points were efficacy, morbidity, and clinical response.

RESULTS

CSEMSs were removed from 65 patients. Resolution of the BBS was confirmed in 59 of 65 patients (90%) after a median follow-up of 12 months after removal (range 3-26 months). If patients who were lost to follow-up, developed cancer, or expired were considered failures, then an intent-to-treat global success rate of 59 of 79 (75%) was obtained. Complications associated with placement included 3 post-ERCP pancreatitis (4%), 1 postsphincterotomy bleed (1%), and 2 pain that required CSEMS removal (2%). In 11 patients (14%), the CSEMS migrated. In 1 patient, CSEMS removal was complicated by a bile leak that was successfully managed with plastic stents.

LIMITATION

Pilot study from a single center.

CONCLUSIONS

Temporary CSEMS placement in patients with BBS offers a potential alternative to surgery.

Postoperative ileus: etiologies and interventions

This article will review the pathophysiology of postoperative ileus, with emphasis on potential therapeutic targets, and examine the efficacy of pharmacologic and nonpharmacologic interventions. Proposed mechanisms include actuation of spinal and local sympathetic neural reflexes, inflammatory mediation, and exacerbation by anesthetic or surgical procedures. Some procedures or agents have shown clinical benefit, and these include use of laparoscopic surgery, thoracic epidurals, nonsteroidal anti-inflammatory drugs, and opiate antagonists. Other procedures may be helpful with low risk of adverse effects. These include early feeding and ambulation, laxatives, and possibly neostigmine.