Jill Gaidos

Prospective evaluation of the long-term outcomes after deep small-bowel spiral enteroscopy in patients with obscure GI bleeding

BACKGROUND Spiral enteroscopy can be safe and effective in the short term for evaluation of obscure GI bleeding, but long-term data are lacking. OBJECTIVE To assess the long-term clinical outcomes after deep small-bowel spiral enteroscopy performed for obscure GI bleeding. DESIGN Prospective cohort study. SETTING Academic referral center. PATIENTS This study included 78 patients who underwent antegrade spiral enteroscopy for evaluation of obscure GI bleeding. INTERVENTION Diagnostic spiral enteroscopy with hemostatic therapeutic maneuvers applied as indicated. MAIN OUTCOME MEASUREMENTS Postprocedure evidence of recurrent overt GI bleeding, blood transfusion requirements, need for iron supplementation, serum hemoglobin values, and the need for additional therapeutic procedures. RESULTS Long-term follow-up data (mean [± standard deviation] 25.3 ± 7.5 months; range 12.9-38.8 months) were obtained in 61 patients (78%). Among those with long-term follow-up data, overt bleeding before spiral enteroscopy was present in 62%, compared with 26% in the follow-up period (P < .0001). The mean (± SD) hemoglobin value increased from 10.6 ± 1.8 to 12.6 ± 1.9 g/dL (P < .0001). Blood transfusion requirements decreased by a mean of 4.19 units per patient (P = .0002), and the need for iron supplementation (P = .0487) and additional procedures (P < .0001) decreased in the follow-up period. There were 8 adverse events (9%) (7 mild, 1 moderate). LIMITATIONS Single-center study, intervention bias. CONCLUSION In patients with obscure GI bleeding, deep small-bowel spiral enteroscopy is safe and effective in reducing the incidence of overt bleeding. An increase in hemoglobin values along with a decrease in blood transfusion requirement, need for iron supplementation, and need for additional therapeutic procedures were found over long-term follow-up. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00861263.).

How to Optimize Colon Cancer Surveillance in Inflammatory Bowel Disease Patients.

Abstract:Colitis-associated colorectal neoplasia (CRN) is a well-known complication of chronic inflammation of the colon either with ulcerative colitis (UC) or colonic Crohns disease (CD). Studies have shown that inflammatory bowel disease (IBD) patients have an overall higher risk for colorectal dysplasia and cancer compared to the general population and this risk is further increased by certain associated factors, including extent of disease, duration of disease, and age at onset. In addition, other risk factors not related to IBD can also further increase the risk for CRN, such as a family history of sporadic colon cancer and a concomitant diagnosis of primary sclerosing cholangitis. The society guidelines mostly agree on the appropriate time to begin CRN surveillance but vary somewhat on the appropriate intervals between surveillance colonoscopies. In addition, there is not yet a consensus on the appropriate method for surveillance. In this review, we discuss the risk for CRN in colonic IBD, the associated factors that further increase the risk for CRN, the current surveillance guidelines and the current methods available for CRN surveillance.

Timing of Last Preoperative Dose of Infliximab Does Not Increase Postoperative Complications in Inflammatory Bowel Disease Patients

BackgroundThe association between preoperative use of infliximab and postoperative complications in patients with inflammatory bowel disease (IBD) is a subject of continued debate. Results from studies examining an association between the timing of last preoperative dose of infliximab and postoperative complications remain inconsistent.AimsTo assess whether timing of last dose of infliximab prior to surgery affects the rate of postoperative complications in patients with Crohn’s disease or ulcerative colitis.MethodsRetrospective chart review of IBD patients who have undergone surgery while receiving therapy with infliximab was conducted. Forty-seven patients were included in the analysis.ResultsNo significant association was found between timing of infliximab and the rate of postoperative complications. Age, gender, disease type, steroid use, preoperative status, surgery type, or surgeon type was not associated with increased rate of postoperative complications.ConclusionTiming of last dose of infliximab does not affect the rate of postoperative complications in patients with Crohn’s disease or ulcerative colitis.

Overcoming challenges of treating inflammatory bowel disease in pregnancy

ABSTRACT Inflammatory bowel disease (IBD) is frequently diagnosed before or during the peak reproductive years. Overall management of inflammatory bowel disease is becoming more complex given the nuances involved with multiple mechanisms of action of the current treatment and need for therapeutic monitoring for safety and efficacy; another layer of complexity is added in the setting of a pregnancy. In this review, we have identified several key challenges that health care providers face when caring for patients with IBD during pregnancy. The goal of this review is to provide the most up-to-date evidence and provide our expert recommendations so that providers can more comfortably address patients’ questions about pregnancy in IBD and the associated risks as well as optimize their care to ensure the best outcomes possible.

Biologics in Pregnancy and Breastfeeding

Inflammatory bowel diseases are commonly first diagnosed in the second and third decades of life and typically require lifelong treatment, which overlaps with the childbearing years. Inflammatory bowel disease (IBD) leads to an increased risk for pregnancy complications and adverse pregnancy outcomes, but having active disease at the time of conception and/or during pregnancy further increases this risk. Preconception counseling about the importance of obtaining disease remission at least 3 months prior to conception as well as the importance of adherence to the appropriate medical treatment in order to maintain remission during pregnancy is paramount to optimizing pregnancy and neonatal outcomes. This chapter will provide the most recent evidence regarding the safety of the currently available biologic medications, including anti-TNFα inhibitors, anti-integrin medications, and anti-IL-12/IL-23 agents, during pregnancy and with breastfeeding.

Health Maintenance Documentation Improves for Veterans with IBD Using a Template in the Computerized Patient Record System

BackgroundInflammatory bowel diseases (IBD) and the therapies used to treat these conditions can lead to preventable complications. In 2011, AGA developed the Adult IBD Physician Performance Measures Set to improve accountability and performance management in IBD care; however, compliance remains poor.AimThe aim of this study is to assess for an improvement in provider compliance with the recommended outpatient preventive care measures in our VA IBD patients after July 2014 following the implementation of a health maintenance template in the Computerized Patient Record system (CPRS).MethodsWe conducted a single-center, retrospective chart review of 139 IBD patients with at least one visit before and after the implementation of the health maintenance template through November 2016. We collected demographic data, immunosuppressive medication use, and recommendations for preventive care. For each variable analyzed, we included those patients where the preventive care measure was indicated based on age, gender, and/or medication use. The McNemar’s test for paired nominal data was used to assess the significant difference in recommendation rate, pre- versus post-template implementation. A p value of < 0.05 was considered significant.ResultsWe included 139 patients (46% with Crohn’s disease, 53% with ulcerative colitis, 1% with indeterminate colitis) in the analysis. Seventy-eight (56%) patients were on immunosuppressants. All preventive care measures significantly improved after implementation of the CPRS template except for HPV vaccination.ConclusionsImplementing a health maintenance template in outpatient GI clinic notes significantly improved provider documentation of the recommended outpatient preventive care in our VA IBD population.

Incidence of and Predictors for Early Discontinuation of Biological Therapies in Veteran Patients with Inflammatory Bowel Disease

Background: Biological therapies are effective for inducing and maintaining remission in inflammatory bowel disease (IBD), but patients often require changes in biological agents over the course of their illness. We sought to evaluate the rate of and reasons for discontinuing biological agents and to identify risk factors for their discontinuation. Methods: We performed a retrospective cohort study across 4 VA hospital systems (Dallas, TX; Houston, TX; Ann Arbor, MI; Richmond, VA). Patients with IBD who were started on biological therapy between 1998 and 2015 were identified, and their medical records were reviewed to confirm the diagnosis of IBD and to collect study data. Results: Of 1969 patients with IBD; 256 were treated with 346 courses of therapy. By 6 months after initiation of therapy, 82 (24%) had stopped the biological agent. Among patients starting their first biological agent, 21.5% had stopped by 6 months. Patients taking a concomitant thiopurine and those with ileocolonic disease or a nonpenetrating, nonstricturing phenotype were less likely to discontinue biological therapy, whereas those taking 5-ASA concomitantly were more likely to discontinue biological therapy. The most common reasons for discontinuation were primary nonresponse (40%) and adverse drug reactions (29%). Conclusions: In conclusion, in a large multicenter VA cohort, we found that 24% of patients who are prescribed a biological stop their treatment early, most commonly for primary nonresponse or for an adverse drug reaction. Consideration should be given to treating patients with a concomitant thiopurine if at all possible, as this reduces the likelihood of early discontinuation.

Sexuality, Fertility, and Pregnancy in Crohn's Disease

Many factors influence the sexual health of people with Crohns disease, but active disease and depression play key roles. The fertility rate in nonoperated patients with inflammatory bowel disease with quiescent disease is similar to that in the general population. Crohns disease can increase the risk for adverse pregnancy outcomes, but being in remission on a stable, steroid-free medication regimen for at least 3 months before conception and adhering to the treatment throughout pregnancy can improve outcomes. Infants with intrauterine exposure to anti-tumor necrosis factor medications should avoid live vaccines for the first 9 months or until drug concentrations are undetectable.

Increased Prevalence of NAFLD in IBD Patients

Nonalcoholic fatty liver disease (NAFLD), a condition affecting approximately a quarter of the general population, is associated with an enormous clinical and economic burden [1]. The estimated prevalence of NAFLD is as high as 40% in patients with inflammatory bowel diseases (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD) [2]. Although multiple etiologies have been proposed to explain this increased NAFLD prevalence, including the presence of the metabolic syndrome (MetS), intestinal inflammation and dysbiosis, and the medications used to treat IBD [3], the underlying cause(s) have yet to be determined. In this issue of Digestive Diseases and Sciences, Carr et al. [4] performed a retrospective analysis of 84 patients with NAFLD and IBD (60 CD and 24 UC), reporting that 23% had MetS. Compared to the cohort without MetS, the cohort with MetS was diagnosed with both MetS and IBD at an older age, had higher transaminase levels, and had higher NAFLD fibrosis scores, although none had advanced fibrosis. The authors therefore suggest that the presence of MetS in IBD patients should prompt further evaluation for NAFLD by a hepatologist for further evaluation and potential long-term care. There was no significant difference in IBD medication use, IBD severity or disease location, or NAFLD severity between the two study groups. This study, which contributes new findings to this growing area of research, is limited by its retrospective design and by the use of International Statistical Classification of Diseases and Related Health Problems (ICD)-9 codes for diagnosis, which may have underestimated the prevalence of NAFLD in the IBD population. Furthermore, the absence of a liver biopsy excluded the possibility of diagnosing more advanced liver disease, including nonalcoholic steatohepatitis and fibrosis, which are challenging to diagnose with current imaging modalities. These and other limitations of this study clearly demonstrate the need for rigorously controlled prospective studies to address some of the most pressing questions, which include the potential interrelationship between the gut microbiome, genetic factors, IBD and NAFLD, respectively.

Managing IBD Therapies in Pregnancy

Opinion statementInflammatory bowel disease is frequently diagnosed before or during key childbearing years. One of the most important factors for a healthy pregnancy is having quiescent disease prior to conception and maintaining disease remission for the duration of the pregnancy. In order to achieve that, most women will need to continue their inflammatory bowel disease (IBD) treatment during pregnancy. One of the main concerns these women have is whether these medications will have adverse effects on their growing fetus. Aminosalicylates, antibiotics, and steroids are all relatively low risk for use during pregnancy and breastfeeding. Recent studies also support the safety of continuing immunomodulators and anti-tumor necrosis factor agents during pregnancy and with breastfeeding. There seems to be an increased risk for infection, however, with use of combination therapy including both a biologic agent and an immunomodulator. Less evidence is available on the use of anti-integrins in pregnancy; however, the current data suggest they may be safe as well. Conversations about a patient’s desire for pregnancy should occur between the patient and provider on a regular basis prior to conception and particularly with any change in disease activity or change in the treatment regimen. This chapter will review the current evidence on the safety of IBD medications during pregnancy and lactation so that providers can more easily discuss the importance of medication adherence for disease remission with their patients who are contemplating conception.