Perioperative management and clinical outcomes of peristomal pyoderma gangrenosum

Peristomal pyoderma gangrenosum is an uncommon subtype of pyoderma gangrenosum mainly affecting stoma sites of patients with inflammatory bowel disease. While surgical treatments are often used to assist healing, little is known about the relationship between surgical interventions and the rate of recurrence of peristomal pyoderma gangrenosum. The aim of this study was to identify patient and clinical factors associated with peristomal pyoderma gangrenosum recurrence following surgical intervention. A multi-institutional retrospective case series and literature review was conducted to evaluate patient characteristics and perioperative treatment. Patients of any age with peristomal pyoderma gangrenosum undergoing surgical operations related to their pyoderma gangrenosum or due to another comorbidity were included. Descriptive statistics were used to characterize demographic information. Associations were evaluated using Wilcoxon's rank-sum test for continuous variables and Fisher's exact test for categorical data. Thirty-seven cases were included, 78.3% of which had a history of inflammatory bowel disease. Overall, 13 (35.1%) cases experienced recurrence at 30 days. There was no significant association identified between patient demographics, stoma location, surgical intervention, or perioperative treatment with rate of recurrence at 30 days post-operation. While no clinical risk factors or treatments were associated with recurrence, our work underscores the importance of a multidisciplinary approach to this disease to address gastrointestinal, dermatologic, and surgical components of treatment.

'Symptom-free' when inflammatory bowel disease is in remission: Expectations raised by online resources

OBJECTIVES

Up to 60% of patients with inflammatory bowel disease (IBD) experience symptoms when in remission. Qualitative research suggests patients seldom feel they receive adequate explanations for these. This study explores how, and how often, ongoing symptoms during remission are represented on readily searchable patient websites.

METHODS

Bing, Google, and Yahoo were searched for websites providing medical information about IBD. Thematic analysis was used to inductively explore themes around symptoms during quiescent IBD, followed by deductive content analysis to quantify core themes.

RESULTS

Results indicated that remission is commonly defined as "few or no symptoms" and that there is limited information available on symptoms during remission. 55.6% of IBD websites provided a definition of remission based on symptom control only, while 44.4% also incorporated inflammatory control. The few websites that mentioned that symptoms may continue during remission (21.7%) related these to IBS.

CONCLUSIONS

Current website information is predominantly biomedical and fails to adequately explain how symptoms may persist during remission and how IBS and IBD may be linked.

PRACTICE IMPLICATIONS

Lack of explanatory models of symptoms in remission may lead to distress and increase anxiety about symptoms. Clearer explanations of these symptoms are needed.

Bariatric Surgery and Inflammatory Bowel Disease: National Trends and Outcomes Associated with Procedural Sleeve Gastrectomy vs Historical Bariatric Surgery Among US Hospitalized Patients 2009-2020

PURPOSE

The association between bariatric surgery and IBD-related inpatient outcomes is not well characterized. We report, analyze, and compare inpatient trends and outcomes among encounters with a history of bariatric surgery (Hx-MBS) compared to those receiving bariatric surgery during index admission (PR-MBS) admitted from 2009 to 2020.

METHODS

Retrospective cohort design: the 2009-2020 National Inpatient Sample (NIS) databases were used to identify hospital encounters with patients aged ≥ 18 years with a history of MBS (Hx-MBS) or with procedure coding indicating MBS procedure (PR-MBS) according to International Classification of Diseases, Ninth (ICD-9-CM/ ICD-9-PCS) or Tenth Revision (ICD-10-CM/ICD-10-PCS) Clinical Modification/Procedure Coding System during index admission (ICD-9-CM: V4586; ICD-10-CM: Z9884; ICD-9-PR: 4382, 4389; ICD-10-PR: 0DB64Z3, 0DB63ZZ). Pearson χ2 analysis, analysis of variance, multivariable regression analyses, and propensity matching on independent variables were conducted to analyze significant associations between variables and for primary outcome inflammatory bowel disease-related admission, and secondary outcomes: diagnosis of nonalcoholic steatohepatitis, nonalcoholic fatty liver disease, or chronic mesenteric ischemia during admission.

RESULTS

We identified 3,365,784 (76.20%) Hx-MBS hospitalizations and 1,050,900 hospitalizations with PR-MBS (23.80%). Propensity score matching analysis demonstrated significantly higher odds of inflammatory bowel disease, and chronic mesenteric ischemia for Hx-MBS compared to PR-MBS, and significantly lower odds of nonalcoholic steatohepatitis and nonalcoholic fatty liver disease for Hx-MBS compared to PR-MBS.

CONCLUSION

In our study, Hx-MBS was associated with significantly increased odds of inflammatory bowel disease and other GI pathologies compared to matched controls. The mechanism by which this occurs is unclear. Additional studies are needed to examine these findings.

Comparison of Fecal Calprotectin with Different Endoscopic Scores in the Assessment of Ulcerative Colitis (UC) Activity and Its Utility in Differentiating IBS from IBD

Background

Ulcerative colitis (UC), a chronic inflammatory disease of gastrointestinal tract, can have initial presentation which is clinically difficult to differentiate from functional bowel disorders [irritable bowel syndrome (IBS) and irritable bowel disease (IBD)]. Conventional laboratory tests, such as erythrocyte sedimentation rate (ESR), C-reactive protein, and albumin express systemic patient responses instead of intestinal inflammation. In the last decade, fecal calprotectin, a calcium-binding protein, has been suggested as a sensitive marker of intestinal inflammation. However, only few studies have investigated its role in relation with the extent of the disease.

Aim

To evaluate the usefulness of fecal calprotectin as a biomarker for disease activity in UC, its correlation with disease extent and its utility in differentiating IBS from IBD.

Methods

A total of 75 patients (50 cases with colonoscopic evidence of inflammation and 25 cases with normal colonoscopic examination) were included in the study. Fecal calprotectin test was done on the day of colonoscopy. Severity of the disease was assessed by modified Mayo's endoscopy score (MMES).

Results

Age and baseline parameters were comparable in both the groups (UC and IBS). Patients in the ulcerative group had tachycardia (95 vs 74), high ESR (26 vs 20), high leukocytes count (9198 vs 8852), high fecal calprotectin (594 vs 29), low albumin (3.00 vs 3.80) and low hemoglobin (11 vs 13.40). Minimum and maximum MMES were 2 and 13.2. A significant correlation was observed between fecal calprotectin and MMES (p-value < 0.001).

Conclusion

Fecal calprotectin is a simple, noninvasive, cost-effective marker that is strongly associated with colorectal inflammation; moreover, it has better role in the differentiation of IBD (UC) from IBS.

How to cite this article

Acharya K, Bhardwaj V, Chuahan I, et al. Comparison of Fecal Calprotectin with Different Endoscopic Scores in the Assessment of Ulcerative Colitis (UC) Activity and Its Utility in Differentiating IBS from IBD. Euroasian J Hepato-Gastroenterol 2023;13(2):120-123.

Epidemiology of irritable bowel syndrome in hospitalized patients with inflammatory bowel disease: Nationwide Inpatient Sample analysis from 2007-2016

BACKGROUND

Despite effective treatments for inflammatory bowel disease (IBD), patients in remission may still suffer from gastrointestinal symptoms attributable to overlying irritable bowel syndrome (IBS). In this population-based cohort study, we investigated the epidemiology of IBS in hospitalized IBD patients and explored the differences between hospitalized IBD-IBS vs. IBD patients to distinguish this patient population.

METHODS

Using the Nationwide Inpatient Sample database from 2007-2016, we identified patients with a primary or secondary discharge diagnosis of IBD, with or without IBS, using ICD-9 and ICD-10 codes. We extracted information on demographics, psychological comorbidities, IBD complications, cost and duration of stay of each group, from either discharge records or diagnosis codes. These were analyzed using SAS version 4.0.

RESULTS

There was a rise in the prevalence of IBS among inpatients with ulcerative colitis (P=0.025) and Crohn's disease (P=0.0014) over the study period. This study revealed that IBD patients with IBS tend to be female, younger, are less likely to be morbidly obese and have higher rates of psychological disorders (P<0.001) compared to IBD patients with no IBS co-diagnosis. They also have fewer IBD-specific complications, such as strictures, obstruction, fistula and abdominal abscess (P<0.001). Shorter hospital stays (P<0.001) and lower hospital charges (P<0.001) were also noted in these patients.

CONCLUSIONS

IBD patients with IBS are significantly different from other IBD patients, and are associated with less severe disease, a shorter hospital stay and lower hospital expenses. Early and accurate classification of this patient population may prevent unnecessary treatment and hospitalization in the future.

Irritable bowel syndrome and functional constipation management with integrative medicine: A systematic review

BACKGROUND

Irritable bowel syndrome (IBS) and functional constipation (FC) are two commonly encountered functional gastrointestinal disorders in clinical practice and are usually managed with Western medicines in cooperation with traditional Chinese medicine (TCM) interventions. Although clinical practice guidelines (CPGs) have been developed to assist clinicians with their decisions, there are still gaps in management with regard to integrative medicine (IM) recommendations.

AIM

To comprehensively review the currently available CPGs and to provide a reference for addressing the gaps in IBS and FC management.

METHODS

We searched mainstream English and Chinese databases and collected data from January 1990 to January 2019. The search was additionally enriched by manual searches and the use of publicly available resources. Based on the development method, the guidelines were classified into evidence-based (EB) guidelines, consensus-based (CB) guidelines, and consensus-based guidelines with no comprehensive consideration of the EB (CB-EB) guidelines. With regard to the recommendations, the strength of the interventions was uniformly converted to a 4-point grading scale.

RESULTS

Thirty CPGs met the inclusion criteria and were captured as data extraction sources. Most Western medicine (WM) CPGs were developed as EB guidelines. All TCM CPGs and most IM CPGs were identified as CB guidelines. Only the 2011 IBS and IM CPG was a CB-EB set of guidelines. Antispasmodics and peppermint oil for pain, loperamide for diarrhea, and linaclotide for constipation were relatively common in the treatment of IBS. Psyllium bulking agents, polyethylene glycol and lactulose as osmotic laxatives, bisacodyl and sodium picosulfate as stimulant laxatives, lubiprostone and linaclotide as prosecretory agents, and prucalopride were strongly recommended or recommended in FC. TCM interventions were suggested based on pattern differentiation, while the recommendation level was considered to be weak or insufficient.

CONCLUSION

WM CPGs generally provide a comprehensive management algorithm, although there are still some gaps that could be addressed with TCM. Specific high-quality trials are needed to enrich the evidence.

The Transient Receptor Potential Vanilloid 4 Agonist RN-1747 Inhibits the Calcium Response to Histamine

BACKGROUND

Sensitization of transient receptor potential (TRP) cation channels probably contributes to intestinal hypersensitivity, a hallmark of gastrointestinal disorders. Histamine acting via histamine 1 receptor (H1R) to open TRP cation channels might also be involved.

METHOD

The enterochromaffin cell line P-STS, responsive to histamine via H1R, was used as model to study possible synergism between histamine and TRP vanilloid 4 (TRPV4) pathways.

RESULTS

The TRPV4 antagonist RN-1734, but not HC-067047, inhibited the cytoplasmic calcium response to histamine in P-STS cells. However, also pre-incubation with the TRPV4 agonist RN-1747 strongly inhibited the calcium response to histamine in P-STS as well as HeLa cells. This inhibitory effect of RN-1747 was not due to its known TRP melastatin 8 (TRPM8) antagonism, as the TRPM8 antagonist RQ-00203078 showed no significant effect on the histamine-induced calcium response of P-STS or HeLa cells.

CONCLUSION

The TRPV4 agonist RN-1747, and possibly also the structurally similar TRPV4 antagonist RN-1734, should be used with caution because of yet unidentified interference with histamine signaling via H1R.

Functional Gastrointestinal Symptoms Are Associated with Higher Serum Total IgE Levels, but Less Atopic Sensitization

BACKGROUND

The relation of gastrointestinal (GI) complaints to IgE-mediated allergy is not well understood. Increased numbers of "IgE-armed" mast cells have been observed in duodenal mucosa of patients with functional GI complaints.

AIMS

To explore whether total IgE and atopic sensitization were associated with functional GI complaints.

METHODS

Levels of serum total and specific IgE and GI complaints were measured in 161 patients and in a general population sample of 478 persons. Standard inhalant allergens were measured in the patient group, and selected inhalant allergens in the general population. GI complaints were assessed by two standardized questionnaires. The associations between GI complaints and total IgE were analyzed in multiple regression models.

RESULTS

GI complaints were positively associated with higher total IgE levels (all: b = 0.028, p = 0.012; patient group: b = 0.038, p = 0.072; general population: b = 0.038, p = 0.005), but negatively associated with atopic sensitization (all: b = -11.256, p = 0.181; patient group: b = -85.667, p < 0.001; general population: b = -14.394, p = 0.083). The relationship between total IgE and GI complaints was consistent among sensitized and non-sensitized persons, among men and women, and across age groups.

CONCLUSION

Serum total IgE was positively associated with GI complaints, while atopic sensitization was inversely associated with GI complaints. This suggests that IgE-mediated immunology plays a role in the pathophysiology of functional GI complaints. The biological mechanisms reflected in higher total IgE levels, but less atopic sensitization, warrant further studies.