Dana C. Moffatt

A Population-Based Study of Breastfeeding in Inflammatory Bowel Disease: Initiation, Duration, and Effect on Disease in the Postpartum Period

OBJECTIVES:We aimed to assess breastfeeding practices and the impact of breastfeeding on disease flare during the postpartum year in inflammatory bowel disease (IBD).METHODS:Women of childbearing age from 1985 to 2005 were identified from the University of Manitoba IBD Research Registry. Questionnaires were completed regarding pregnancy and the postpartum period. Data for initiation and duration of breastfeeding were compared with population-based regional data.RESULTS:Of 204 eligible women, 132 (64.7%) responded to the survey, yielding information on 156 births. Breastfeeding was initiated in 83.3% of women with IBD (n=132), 81.9% of Crohns disease patients (CD, n=90), and 84.2% of ulcerative colitis patients (UC, n=39) vs. 77.1 % in the general population (P>0.05 for all). Of women with IBD, 56.1% breastfed for >24 weeks vs. 44.4% of controls (P=0.02). The rate of disease flare in the postpartum year was 26% for those who breastfed vs. 29.4% in those who did not (P=0.76) in CD and 29.2% vs. 44.4% (P=0.44) in UC. The odds ratio of disease flare postpartum for those who breastfed vs. those who did not was 0.58 (95% CI: 0.24–1.43), 0.84 (0.19–9.87), and 0.51 (0.12–2.2) for IBD total, CD, and UC, respectively. Risk of disease flare was not related to age at pregnancy, duration of disease, or socioeconomic status.CONCLUSIONS:Women with IBD are as likely as the general population to breastfeed their infants. Breastfeeding is not associated with an increased risk of disease flare and may even provide a protective effect against disease flare in the postpartum year.

Risk factors for ERCP-related complications in patients with pancreas divisum: a retrospective study

BACKGROUND Limited data are available on complication rates of ERCP in patients with pancreas divisum (PD), and it is unclear whether traditional risk factors for post-ERCP pancreatitis (PEP) apply. OBJECTIVES To describe the rates of ERCP complications in patients with PD and assess patient and procedure-related risk factors for PEP. DESIGN Retrospective cohort study. SETTING Tertiary care referral center. PATIENTS A total of 2753 ERCPs performed in 1476 patients with PD from 1997 to 2010. MAIN OUTCOME MEASUREMENTS Rates of PEP, hemorrhage, perforation, cholecystitis, and hospitalization directly attributable to ERCP. RESULTS Early complications occurred after 7.8% of procedures, with PEP, hemorrhage, perforation, cholecystitis, and cardiorespiratory complications in 6.8%, 0.7%, 0.2%, 0.1%, and 0.1% of procedures, respectively. PEP was uncommon in patients who did not undergo attempted dorsal duct cannulation, occurring in 1.2% of procedures. With dorsal duct cannulation and cannulation with minor papilla sphincterotomy (MiS), the rates of PEP increased significantly to 8.2% and 10.6%, respectively (P<.01 for each comparison). Significant predictors of PEP after multivariate logistic regression included age younger than 40 (odds ratio [OR] 1.8; 95% CI, 1.27-2.59), female sex (OR 1.94; 95% CI, 1.25-3.01), previous PEP (OR 2.02; 95% CI, 1.32-3.1), attempted dorsal duct cannulation (OR 7.45; 95% CI, 3.25-17.07), and MiS (OR 1.62; 95% CI, 1.05-2.48). Presence of severe chronic pancreatitis was a protective factor (OR 0.46; 95% CI, 0.22-0.98). LIMITATIONS Retrospective analysis of prospectively collected data. CONCLUSIONS Among patients with PD, the rate of PEP is low (1.2%) if dorsal duct cannulation is not attempted. However, patients with PD undergoing dorsal duct cannulation with or without MiS are at high risk of PEP (8.2% without and 10.6% with). Traditional PEP risk factors apply to patients with PD.

Choledochoceles: are they choledochal cysts?

Objective:The aim of this analysis was to report a multidisciplinary series comparing choledochoceles to Todani Types I, II, IV, and V choledochal cysts. Summary Background Data:Choledochoceles have been classified as Todani Type III choledochal cysts. However, most surgical series of choledochal cysts have reported few choledochoceles because they are managed primarily by endoscopists. Methods:Surgical, endoscopic, and radiologic records were reviewed at the Riley Childrens Hospital and the Indiana University Hospitals to identify patients with choledochal cysts. Patient demographics, presenting symptoms, radiologic studies, associated abnormalities, surgical and endoscopic procedures as well as outcomes were reviewed. Results:A total of 146 patients with “choledochal cysts” including 45 children (31%) and 28 with choledochoceles (18%) were identified, which represents the largest Western series. Patients with choledochoceles were older (50.7 vs. 29.0 years, P < 0.05) and more likely to be male (43% vs. 19%, P < 0.05), to present with pancreatitis (48% vs. 24%, P < 0.05) rather than jaundice (11% vs. 30%, P < 0.05) or cholangitis (0% vs. 21%, P < 0.05), to have pancreas divisum (38% vs. 10%, P < 0.01), and to be managed with endoscopic therapy (79% vs. 17%, P < 0.01). Two patients with choledochoceles (7%) had pancreatic neoplasms. Conclusions:Patients with choledochoceles differ from patients with choledochal cysts with respect to age, gender, presentation, pancreatic ductal anatomy, and their management. The association between choledochoceles and pancreas divisum is a new observation. Therefore, we conclude that classifications of choledochal cysts should not include choledochoceles.

Pyogenic granuloma: An unusual cause of massive gastrointestinal bleeding from the small bowel

Small bowel hemorrhage is responsible for approximately 4% of all cases of gastrointestinal bleeding. The etiology of bleeding from the small bowel is a tumour in approximately 10% of cases. Pyogenic granuloma is a common inflammatory vascular tumour of the dermis, which rarely occurs in the gastrointestinal tract. Pyogenic granuloma is a rare cause of overt or obscure small bowel bleeding. The present paper reports the first case of pyogenic granuloma presenting as a massive gastrointestinal bleed, and reviews the relevant literature to date regarding the clinical presentation, diagnosis and management of this rare gastrointestinal lesion.

Trends in utilization of diagnostic and therapeutic ERCP and cholecystectomy over the past 25 years: a population-based study.

BACKGROUND Comprehensive, population-based data on ERCP use over the last 30 years in North America are lacking. OBJECTIVE To establish crude and age-adjusted population-based rates of ERCP, evaluate for changing indications for ERCP, and evaluate for interactions between cholecystectomy technique and ERCP use from 1984 to 2009. DESIGN Retrospective, comprehensive, population-based study. SETTING All inpatient and outpatient ERCPs and cholecystectomies in Manitoba, Canada from 1984 to 2009. PATIENTS All residents of Manitoba, Canada with a history of ERCP and/or cholecystectomy. INTERVENTION None. MAIN OUTCOME MEASUREMENTS Yearly crude and age-adjusted rates of ERCP (diagnostic and therapeutic) and cholecystectomy (open, laparoscopic, and with open bile duct exploration), and patient and/or procedure demographics. RESULTS The rate of ERCP/10,000 people increased from 7.70 (1984) to 13.86/10,000 (2009) (P = .001). Diagnostic ERCP declined from 7.28/10,000 (1984) to 1.11/10,000 (2009), and therapeutic ERCP increased from 0.42/10,000 (1984) to 12.75/10,000 (2009) (P < .001). ERCPs were more common in women (62%) and in older populations (60-79 years, >80 years), with rates of therapeutic ERCP reaching 62.58/10,000 in the elderly. The primary indication for ERCP has changed over time, with biliary indications increasing from 50.3% to 67.3% and pancreatic indications decreasing from 18.3% to 8.1% (P < .05). The rate of therapeutic ERCP increased during the transition from open to laparoscopic cholecystectomy (1991-1994), whereas open bile duct exploration (OBDE) decreased from 2.0 to 0.18/10,000 (P < .001). LIMITATIONS Retrospective analysis, administrative data. CONCLUSION ERCP use increased steadily from 1984 to 2009, and changed from a diagnostic modality to a therapeutic one. Changes in cholecystectomy technique may have influenced therapeutic ERCP use and likewise, the availability of therapeutic ERCP has decreased the need for OBDE.

Acute pancreatitis after removal of retained prophylactic pancreatic stents

BACKGROUND Prophylactic pancreatic stents (PPSs) are used to decrease the risk of post-ERCP pancreatitis (PEP) in high-risk patients. The risk associated with PPS removal is unknown. OBJECTIVE To describe the rate of PEP in patients undergoing PPS removal without pancreatogram or other manipulation of the major or minor papilla. DESIGN Retrospective, cohort study. SETTING Tertiary care academic center. PATIENTS This study involved 230 patients undergoing removal of PPSs from 1997 to 2010. INTERVENTION PPS removal. MAIN OUTCOME MEASUREMENTS Rate of acute pancreatitis associated with removal of PPS alone. RESULTS Acute pancreatitis occurred after PPS removal in 7 of 230 (3.0%) cases. PEP was graded as mild, moderate, and severe in 2, 5, and 0 cases, respectively. Statistically significant risk factors of PEP after PPS removal include use of a 5F stent (P=.001), use of a stent with an internal flange (P<.01), and occurrence of PEP after the initial ERCP (P<.01). Longer duration of stent within the pancreatic duct before removal was of borderline significance (P=.06). Patient age; sex; indication for initial procedure; the presence of pancreas divisum, ansa loop, or chronic pancreatitis; and history of pancreatic or biliary sphincterotomy or orifice dilation were not significant risk factors for pancreatitis after PPS removal. LIMITATIONS Retrospective analysis of prospectively collected data. Small number of events. CONCLUSION Removal of retained PPSs may cause mild or moderate acute pancreatitis. This risk of acute pancreatitis may diminish the overall efficacy of PPS use by delaying the occurrence of PEP rather than eliminating it. This implies that PPSs should be used only in patients at high risk for PEP.

Moderate and severe postendoscopic retrograde cholangiopancreatography pancreatitis despite prophylactic pancreatic stent placement: The effect of early prophylactic pancreatic stent dislodgement

BACKGROUND Placement of prophylactic pancreatic stents (PPS) is a method proven to reduce the rate and severity of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk patients; however, PPS do not eliminate the risk completely. Early PPS dislodgement may occur prematurely and contribute to more frequent or severe PEP. OBJECTIVE To determine the effect of early dislodgement of PPS in patients with moderate or severe PEP. METHODS A total of 27,176 ERCP procedures from January 1994 to September 2007 for PPS placement in high-risk patients were analyzed. Patient and procedure data were analyzed to assess risk factors for PEP, and to evaluate the severity of pancreatitis, length of hospitalization and subsequent complications. Timing of stent dislodgment was assessed radiographically. RESULTS PPS were placed in 7661 patients. Of these, 580 patients (7.5%) developed PEP, which was graded as mild in 460 (6.0%), moderate in 87 (1.1%) and severe in 33 (0.4%). Risk factors for developing PEP were not different in patients who developed moderate PEP compared with those with severe PEP. PPS dislodged before 72 h in seven of 59 (11.9%) patients with moderate PEP and five of 27 (18.5%) patients with severe PEP (P=0.505). The mean (± SD) length of hospitalization in patients with moderate PEP with stent dislodgement before and after 72 h were 7.43 ± 1.46 days and 8.37 ± 1.16 days, respectively (P=0.20). The mean length of hospitalization in patients with severe PEP whose stent dislodged before and after 72 h were 21.6 ± 6.11 and 22.23 ± 3.13 days, respectively (P=0.96). CONCLUSION Early PPS dislodgement was associated with moderate and severe PEP in less than 20% of cases and was not associated with a more severe course. Factors other than ductal obstruction contribute to PEP in high-risk patients undergoing ERCP and PPS placement.

State-of-the-Art Medical Therapy of the Adult Patient with IBD: The Immunomodulators

AZA/6-MP are the most well-studied immunomodulators effective at reducing steroid use, inducing and maintaining remission in CD and UC. TPMT phenotype (genotype if phenotype not available) should be checked in all patients before initiating therapy with AZA or 6-MP, to avoid profound bone marrow toxicity and to facilitate more complete dosing earlier. Methotrexate is an effective alternative to AZA/6-MP in Crohn’s disease and possibly in UC if given parenterally at doses >15 mg/week. Cycosporine A is effective at inducing remission in severe UC, and may lead to a reduced rate of colectomy if used as a bridge to long-term AZA or 6-MP therapy. Tacrolimus, mycophenolate mofetil, and thalidomide may have a role as third line immunomodulators in complicated or fistulizing CD. 6-Thioguanine should not be used as a therapy for active IBD due to frequent hepatotoxicity and occurrence of nodular regenerative hyperplasia.

Determining the natural history of pancreatic cystic neoplasms: a Manitoban cohort study

BACKGROUND Most pancreatic cystic neoplasms (PCN) are thought to harbor a low malignant potential. This historical cohort study attempts to describe the natural history of these lesions in a provincial cohort, to assess the safety of non-surgical management. Pathological diagnosis of malignancy was the primary outcome measure of interest. METHODS All adult patients (age 18+) with PCN seen between 2000 and 2012 by the two main institutions in Manitoba were included in this study. PCN were graded as high and low risk, which dictated initial treatment plan (surgery or observation). Predictors of initial surgical treatment, delayed surgery in the observation group and the clinical/radiological predictors of malignancy were determined. RESULTS 497 patients were included in this study. 43 (8.7%) high-risk lesions underwent initial surgery, with 13 (30.2%) cases of malignancy discovered. 450 (90.5%) low-risk cysts were observed for a median of 17.3 months (range: 0.00-142.3). 29 (6.4%) cases of delayed surgery occurred, with malignancy discovered in five (17.2%). CONCLUSIONS This study supports current selection criteria for management of PCNs. Due to the low incidence of malignancy in low-risk PCN, it appears that long-term observation is safe and should be the treatment modality of choice in the absence of high-risk features.

35 A Population Based Study of Breastfeeding in Inflammatory Bowel Disease: Initiation, Duration and Effect On Disease in the Post Partum Period

Hospitalizations were more frequent in the 3 groups of smokers (LS 15%, MS 16%, HS 15%) compared to the NS group (13%, p<0.01 for each comparison). This higher level of activity was observed despite a significantly increased use of immunosuppressants (LS 38%, MS 44%, HS 40% vs. NS 36%, p<0.05 for each comparison). Anti-TNF requirement was similar in the 4 groups (5.8 to 6.9% during the period 1999-2007). The annual percentage of patients with intestinal resection between 1995 and 2007 tended to be higher in the 3 groups of smokers (LSF 5.1%, MS 6.4%, HS 5.6%, vs. NS 4.8%) but the difference was significant only in the MS group. Conclusion: In CD, deleterious effect of tobacco consumption is dose-dependent. This harmful effect is observed evenwith a light tobacco consumption. Indeed patients in the LS group had amore active disease and requiredmore immunosuppressants compared with non smokers. Complete smoking cessation should remain a major therapeutic goal.