C Alexakis

Small intestinal contrast ultrasonography for the detection of small bowel complications in Crohn's disease: correlation with intraoperative findings and magnetic resonance enterography.

In evaluating small bowel Crohns disease (CD), small intestine contrast‐enhanced ultrasonography (SICUS) is emerging as an alternative to magnetic resonance enterography (MRE). This retrospective study compared the diagnostic accuracy of SICUS and MRE with surgical findings, and their level of agreement.

Impact of thiopurines and anti-tumour necrosis factor therapy on hospitalisation and long-term surgical outcomes in ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory condition affecting the large bowel and is associated with a significant risk of both requirement for surgery and the need for hospitalisation. Thiopurines, and more recently, anti-tumour necrosis factor (aTNF) therapy have been used successfully to induce clinical remission. However, there is less data available on whether these agents prevent long-term colectomy rates or the need for hospitalisation. The focus of this article is to review the recent and pertinent literature on the long-term impact of thiopurines and aTNF on long-term surgical and hospitalisation rates in UC. Data from population based longitudinal research indicates that thiopurine therapy probably has a protective role against colectomy, if used in appropriate patients for a sufficient duration. aTNF agents appear to have a short term protective effect against colectomy, but data is limited for longer periods. Whereas there is insufficient evidence that thiopurines affect hospitalisation, evidence favours that aTNF therapy probably reduces the risk of hospitalisation within the first year of use, but it is less clear on whether this effect continues beyond this period. More structured research needs to be conducted to answer these clinically important questions.

Effects of eosinophilic oesophagitis on quality of life in an adult UK population: a case control study

Eosinophilic oesophagitis (EoE) is a chronic immune-mediated esophageal disease, characterized by symptoms related to esophageal dysfunction and histologically by eosinophil predominant inflammation. Current evidence for an adverse impact on quality of life (QoL) is conflicting and there are no data from a UK population regarding QoL. We conducted a prospective cross-sectional observational study using the Short Form-36 Health Survey, Hospital Dysphagia/Odynophagia Questionnaire, and the EoE Adult Quality of Life Questionnaire to assess QoL and severity of dysphagia in EoE patients, compared to age and gender matched healthy control subjects. Data were also collected on comorbidity and medication use. Eighty-eight subjects were recruited (44 patients). Patients had higher rates of antihistamine and topical (swallowed) corticosteroid use. Physical QoL did not differ between patients and controls, although patients did report a statistically significant lower mental QoL, with small absolute magnitude of difference. Patients reported higher dysphagia scores and these were negatively correlated with both physical and mental QoL. Higher rates of dysphagia and medication use in patients may among other things account for lower mental QoL. However, a higher rate of dysphagia in patients is not associated with a reduced physical QoL. Our findings are of clinical value, particularly when a new diagnosis of EoE is made, as clinicians can reassure patients that their general physical health should not be greatly affected by the diagnosis. Moreover, it may also be useful for patients to be aware that EoE may have an impact on their mental health, but this effect is likely to be small. We therefore advocate education and reassurance in this respect for all patients at diagnosis.

Proposed case of mesalazine-induced cardiomyopathy in severe ulcerative colitis.

Five-amino salicylic acids are recommended for use in the management of inflammatory bowel disease, cardiac complications are a rare although recognised phenomenon. This report aims to highlight this serious but rare adverse reaction. We report here a case of a young man presenting with cardiogenic shock in the context of recent mesalazine treatment in severe ulcerative colitis.

PWE-106 Small Intestine Ultrasonography With Oral Contrast (sicus) For The Detection Of Small Bowel Complications In Crohn’s Disease: Correlation With Intra-operative Findings

Introduction SICUS accurately assesses small bowel lesions in patients with Crohn’s disease (CD) without exposure to diagnostic medical radiation.1 Its role in identifying intra-abdominal complications associated with CD remains to be confirmed. The aim of this retrospective study was to compare the diagnostic sensitivity of SICUS with subsequent surgical findings. Methods Patients with CD evaluated by SICUS who subsequently required bowel resection within 6 months were identified. Radiological findings and operation notes were collated. The accuracy and agreement of SICUS to detect the site and length of strictures, fistulae, abscesses and mucosal thickening, was compared with surgical findings and assessed by kappa (κ) coefficient statistical analysis. Stricture lengths were compared using student’s t-test. CRP and platelet count were recorded within 2 weeks of SICUS and surgery as surrogate markers of disease activity. Results A total of 25 patients (12 male) with a mean age of 29.9 years were included in the study. Mean time from SICUS to respective bowel surgery was 91.5 days (Range 5–176). Ultrasonographic and surgical inter-rater agreement was good for the presence of strictures (κ=0.73, sensitivity and specificity both 88%), their number (κ=0.65, 95% CI: 0.31–0.96) and stricture site (κ =0.72, 95% CI: 0.44–1.00). Stricture length was 7.4 ± 1.5 cm identified at surgery vs. 5.8 ± 1.8 cm by SICUS (NS). Agreement was excellent for the presence of fistulae (κ = 0.82, sensitivity 86%, specificity 94%), location of fistula (κ=0.92, 95% CI: 0.76–1.00), presence of abscess (κ = 0.87, sensitivity 100%, specificity 95%) and its location (κ = 0.87, 95% CI: 0.63–1.00). Agreement was moderate for mucosal wall thickening (κ = 0.51, sensitivity 95%, specificity 50%). Markers of inflammation (CRP and platelet count) showed no significant difference at the time of SICUS and surgery. Conclusion SICUS accurately identifies small bowel complications in CD and offers an alternative in the pre-operative stage of CD complications. Its wider use should be adopted. Reference Chatu S, Pilcher J, Saxena SK, et al. Diagnostic accuracy of small intestine ultrasonography using an oral contrast agent in Crohn’s disease: comparative study from the UK. Clin Radiol 2012 Jun;67(6):553–9 Disclosure of Interest None Declared.

Delayed diagnosis of lymphogranuloma venereum-associated colitis in a man first suspected to have rectal cancer

Lymphogranuloma venereum-associated colitis is a diagnosis that should not be missed. The following case represents the importance of a thorough history, including the importance of the sexual history to prevent the misdiagnosis of these patients.

PTU-052 The Impact of Thiopurines on Risk of Intestinal Surgery in Elderly-Onset IBD: Abstract PTU-052 Table 1

Introduction Thiopurines (TP) have an established role in the maintenance of steroid-free remission in IBD. Their role in reducing the need for surgery in younger populations has been recently highlighed.1 TPs are associated with an increased risk of lymphoma in the elderly but their role in reducing the risk of surgery in patients with elderly-onset IBD (EO-IBD) is not established. We therefore aimed to evaluate the impact of TPs on the risk of surgery in EO-IBD, using a nationally representative research database. Methods This was a retrospective descriptive study using data from the Clinical Practice Research Datalink (CPRD). Incident cases of IBD were isolated using previously validated Read codes. Patients were included if they had codes for ulcerative colitis (UC) or Crohn’s disease (CD), and their date of diagnosis was on/after their 60 th birthday. Information extracted included sex, age at diagnosis, smoking status, and prescription data for IBD medications. Finally, we obtained data on our main outcomes: colectomy in UC and first intestinal surgery in CD. A multivariate Cox proportional hazard model was generated to deduce the risk of surgery according to TP use. The model was adjusted for potential confounders including sex, smoking, 5 ASA use and early steroid use (corticosteroid within 3 months of diagnosis). In a subgroup of TP users, a second proportional hazard model was used to define the impact of duration of TP treatment on the risk of surgery. Results 2758 and 1349 were identified with EO-UC and EO-CD respectively, with a mean follow up of 4.9 years. Mean age at diagnosis was 71.8 years. Table 1 demonstrates the summary demographic and prescription data for both groups.Abstract PTU-052 Table 1 Elderly-onset UC Elderly-onset CD Male 50% 40% Smoking at diagnosis 9% 22% 5 ASA use 80% 63% Steroid use 56% 52% Thiopurine use 13% 16% Surgery 4% 13% TP use was associated with an increased risk of colectomy in EO-UC (HR 3.5, CI 2.28–5.35, p < 0.0001), but not an increased risk of first intestinal surgery in EO-CD. In subgroup analysis restricted to TP users only, TP use for greater than 12 months in EO-UC was associated with a 64% reduction in risk of colectomy (HR 0.36, CI 0.18–0.7, p = 0.003). Similar findings were not seen in EO-CD. Conclusion TP use for longer than 12 months is associated with a reduced risk of colectomy in EO-UC but in contrast does not appear appear to impact on the risk of first intestinal surgery in EO-CD. This is an important observation since the risk of TP-associated lymphoma is substantially increased in this age group. Further work is needed to evaluate the role of TPs in EO-IBD. Reference 1 Chhaya V, et al. Impact of early thiopurines in 2770 children and young people diagnosed with IBD: a national population-based study. Aliment Pharmacol Ther. 2015 Oct;42(8). Disclosure of Interest C. Alexakis: None Declared, S. Saxena Grant/research support from: SS is funded by a National Institute for Health Research Career Development Fellowship (NIHR CDF-2011-04-048). The views expressed are not necessarily those of the NHS, NIHR, or Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript, V. Chhaya: None Declared, E. Cecil Grant/research support from: EC is funded by a National Institute for Health Research Career Development Fellowship (NIHR CDF-2011-04-048). The views expressed are not necessarily those of the NHS, NIHR, or Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript, R. Pollok: None Declared

PWE-064 The Utility of An Enteric Bacterial PCR Panel In Evaluating Patients with Diarrhoea and Raised Faecal Calprotectin

Introduction Faecal calprotectin (FCP) assay has an important role in identifying potential cases of inflammatory bowel disease (IBD). However, a significant proportion of patients presenting with diarrhoea and raised FCP do not prove to have IBD following investigation of whom a proportion have an acute self-limiting gut infection. Enteric pathogens are alternative causes of a raised FCP. Alleviating the need for endoscopy in the patients will save money and reduce patient anxiety. However, conventional laboratory methodologies are time consuming and insensitive in detecting gut infection. Commercial nucleic acid amplification test (NAAT) technology now makes it possible to test stool for a panel of gut pathogens quickly and relatively cheaply. In this pilot study, we evaluated this technology in detecting gut infection amongst patients with a diarrhoeal illness and raised FCP, presenting in the community. Methods Ninety patients with diarrhoea had stool samples submitted from the community to the laboratory for FCP measurement. Samples were anonymised before testing with NAAT (BD MAX™ Enteric Bacterial Panel). The targets of this assay are Salmonella spp., Campylobacter spp. Shigella (Shigella spp. and enteroinvasive E. coli) and verotoxigenic E coli. Samples were stratified by FCP level into sub-groups (n = 30): <50, 50–150, >150 µg/g stool and analysed for the presence and type of gut infection found. All samples were also cultured using standard media. Results 2/30 samples tested (7%, 95% CI 8–23%) with FCP > 150 µg/g tested positive by NAAT for Campylobacter. No patients with FCP below 150 µg/g had a detectable pathogen. No samples were positive by conventional culture methods. Conclusion This pilot study supports a role for the use of multiplex NAAT in detecting enteric pathogens amongst patients with diarrhoea and raised FCP. Prospective studies are required to evaluate this approach further which offers the potential to refine the IBD referral pathways from primary care and reduce the need for endoscopic and radiological tests. Disclosure of Interest None Declared

PWE-070 Perspectives And Attitudes To Colonoscopy In Patients With Inflammatory Bowel Disease

Introduction Visualisation of mucosa at ileocolonoscopy (IC) remains the gold standard in the assessment of mucosal healing (MH) in patients with inflammatory bowel disease (IBD). MH is evolving as a key endpoint in assessing response to therapy. This will invariably mean an increased endoscopic burden on these patients. We aimed to investigate IBD patients’ perspectives on this, as well as their tolerance of IC. Methods Consecutive patients attending IBD clinic between September and December 2013 were questioned on their experience of IC. Data on sex, age, disease type (Crohn’s (CD) or ulcerative colitis (UC)), duration of illness, and no. of IC was obtained. They were asked to grade various components of the IC experience (concerns about complications, bowel preparation, disruption to life, procedure discomfort, travel to hospital) on a standardised tolerance scale from 1–5. They were also asked to qualitatively rate their overall experience of IC (not unpleasant/neither unpleasant nor pleasant/bearable/unpleasant/very unpleasant). Finally, they were asked how often they would be prepared to undertake IC in the future. Results 98 patients responded (46% male). Mean age was 43.2 years. 33 had UC, 50 had CD, and 11 were unsure of diagnosis. Mean no. IC was 3.7. 62% had a disease duration >5 years, with only 4% diagnosed in the previous year. Mean tolerance scores for the group were: concerns about complications 2.6, bowel preparation 3.0, disruption to life 2.4, discomfort during procedure 3.0, travel to/from hospital 1.7. Comparisons between patient subgroups CD versus UC, age ≥55 years versus age <55 years, ≥4 IC versus <4 IC, and diagnosis ≥5 years versus diagnosis <5 years, revealed no significant differences in scores. However, comparison between sexes showed females were more worried about the procedure than males (3.0 vs. 2.1, p = 0.02), were less tolerant of bowel preparation (3.5 vs. 2.3, p < 0.001), experienced more disruption to their lives (2.9 vs. 1.9, p < 0.001) and were more troubled by travel concerns (2.0 vs. 1.4, p = 0.02). The majority of the patients felt IC was bearable (53%) with only 13% describing it as very unpleasant. 55% would have the procedure as frequently as required if their physician felt it appropriate. 7% would only have IC every 5 years. Conclusion Bowel preparation and procedural discomfort are the most bothersome aspects of IC amongst IBD patients. There are clear differences in tolerance between female and male patients, and these results should prompt endoscopy units to find ways of improving patient acceptability. This could be provided in the form of a pre-test telephone consultation. A minority of patients were reluctant to increase their frequency of IC, which may be relevant in the monitoring of MH in their future management. Disclosure of Interest None Declared.

PTU-073 Comparison Of Sicus Versus Mr-enterography In Patients With Crohn’s Disease

Introduction Small intestinal contrast-enhanced ultrasonography (SICUS) is an emerging radiological technique for the imaging of patients with Crohn’s disease that avoids exposure to diagnostic medical radiation. We have previously demonstrated that SICUS is diagnostically comparable to small bowel barium follow through and computerised tomography in the diagnosis of Crohn’s.1 MR enterography (MRE) is becoming the gold standard radiological technique for the diagnosis of complications in patients with Crohn’s, but is expensive and access is limited. We aimed to compare the diagnostic sensitivity of SICUS with MRE in routine clinical practice. Methods Patients with established Crohn’s disease, who had undergone both SICUS and MRE within 6 months of each other were identified retrospectively from the radiology database at a UK tertiary centre. Imaging and reports were reviewed for both modalities. Kappa coefficient data was calculated for luminal parameters including the presence of strictures, stricture number and location, the presence of abscess/fistulae, mucosal thickening, active mucosal inflammation and fibrotic changes. Reported stricture lengths were compared using paired student’s t-test. Inflammatory markers including platelet levels, where available, were recorded within 2 weeks of each of the imaging modalities as a surrogate marker for active inflammation. Results 20 Crohn’s patients were identified (10 male), with a mean age of 30.1 years at time of first investigation. Mean time between modalities was 72.3 days (range 2–147). There was no significant difference between mean platelet counts between the 2 radiological tests. Agreement between the 2 modalities was excellent for the presence of stricturing disease (k=0.92, 95% CI 0.71–1.00), stricture number (k=0.91, 95% CI 0.73–1.00) and stricture location (k=0.91, 95% CI 0.71–1.00). Agreement was good for the presence of fistulae (k=0.74, 95% CI 0.40–1.00) and mucosal thickening (k=0.74, 95% CI 0.40–1.00). Agreement was moderate for the presence of abscess (k=0.46 95% CI 0.14–1.00), acute mucosal inflammatory changes (k=0.55, 95% CI 0.19–0.90) and fibrotic changes (k=0.50, 95% CI 0.04–0.95). There was no significant difference in the mean estimated stricture length between MRE and SICUS. Conclusion SICUS compares favourably with MRE in the diagnosis of complications in patients with Crohn’s disease. This imaging technique is particularly useful in patients with stricturing (Montreal B2) disease. SICUS is a useful alternative diagnostic technique to MRE, particularly when access to MR may be limited or is poorly tolerated by the patient. Reference Chatu S et al. Diagnostic accuracy of small intestine ultrasonography using an oral contrast agent in Crohn’s disease: comparative study from the UK. Clin Radiol. 2012 Jun;67(6):553-9 Disclosure of Interest None Declared.