Joana Magalhães

Validation of the Lewis score for the evaluation of small-bowel Crohn’s disease activity

BACKGROUND AND STUDY AIMSnThe Lewis score was developed to measure mucosal inflammatory activity as detected by small-bowel capsule endoscopy (SBCE). The aim of the current study was to validate the Lewis score by assessing interobserver correlation and level of agreement in a clinical setting.nnnPATIENTS AND METHODSnThis was a retrospective, single-center, double-blind study including patients with isolated small-bowel Crohns disease who underwent SBCE. The Lewis score was calculated using a software application, based on the characteristics of villous edema, ulcers, and stenoses. The Lewis score was independently calculated by one of three investigators and by a central reader (gold standard). Interobserver agreement was assessed using intraclass correlation (ICC) coefficient and Blandu200a-u200aAltman plots.nnnRESULTSnA total of 70 patients were consecutively included (mean age 33.9u200a±u200a11.7 years). The mean Lewis score was 1265 and 1320 for investigators and the central reader, respectively. There was a high correlation, both for scores obtained for each tertile (first tertile ru200a=u200a0.659u200a-u200a0.950, second tertile ru200a=u200a0.756u200a-u200a0.906, third tertile ru200a=u200a0.750u200a-u200a0.939), and for the global score (ru200a=u200a0.745u200a-u200a0.928) (Pu200a<u200a0.0001). Interobserver agreement was almost perfect between the investigators and the central reader (first tertile ICCu200a=u200a0.788u200a-u200a0.971, second tertile ICCu200a=u200a0.824u200a-u200a0.943, third tertile ICCu200a=u200a0.857u200a-u200a0.968, global score ICCu200a=u200a0.852u200a-u200a0.960; Pu200a<u200a0.0001). The inflammatory activity was classified as normal (scoreu200a<u200a135) in 2.9u200a% vs. 2.9u200a%, mild (scoreu200a≥u200a135u200a-u200a<u200a790) in 51.4u200a% vs. 55.7u200a%, and moderate to severe (scoreu200a≥u200a790) in 45.8u200a% vs. 41.4u200a% of patients, respectively (Pu200a<u200a0.001).nnnCONCLUSIONnA strong interobserver agreement was demonstrated for the determination of the Lewis score in a practical clinical setting, validating this score for the reporting of small-bowel inflammatory activity. The Lewis score might be used for diagnosing, staging, follow-up, and therapeutic assessment of patients with isolated small-bowel Crohns disease.

Oral purgative and simethicone before small bowel capsule endoscopy

AIMnTo evaluate small bowel cleansing quality, diagnostic yield and transit time, comparing three cleansing protocols prior to capsule endoscopy.nnnMETHODSnSixty patients were prospectively enrolled and randomized to one of the following cleansing protocols: patients in Group A underwent a 24 h liquid diet and overnight fasting; patients in Group B followed protocol A and subsequently were administered 2 L of polyethylene glycol (PEG) the evening before the procedure; patients in Group C followed protocol B and were additionally administered 100 mg of simethicone 30 min prior to capsule ingestion. Small bowel cleansing was independently assessed by two experienced endoscopists and classified as poor, fair, good or excellent according to the proportion of small bowel mucosa under perfect conditions for visualization. When there was no agreement between the two endoscopists, the images were reviewed and discussed until a consensus was reached. The preparation was considered acceptable if > 50% or adequate if > 75% of the mucosa was in perfect cleansing condition. The amount of bubbles was assessed independently and it was considered significant if it prevented a correct interpretation of the images. Positive endoscopic findings, gastric emptying time (GET) and small bowel transit time (SBTT) were recorded for each examination.nnnRESULTSnThere was a trend favoring Group B in achieving an acceptable (including fair, good or excellent) level of cleansing (Group A: 65%; Group B: 83.3%; Group C: 68.4%) [P = not significant (NS)] and favoring Group C in attaining an excellent level of cleansing (Group A: 10%; Group B: 16.7%; Group C: 21.1%) (P = NS). The number of patients with an adequate cleansing of the small bowel, corresponding to an excellent or good classification, was 5 (25%) in Group A, 5 (27.8%) in Group B and 4 (21.1%) in Group C (P = 0.892). Conversely, 7 patients (35%) in Group A, 3 patients (16.7%) in Group B and 6 patients (31.6%) in Group C were considered to have poor small bowel cleansing (P = 0.417), with significant fluid or debris such that the examination was unreliable. The proportion of patients with a significant amount of bubbles was 50% in Group A, 27.8% in Group B and 15.8% in Group C (P = 0.065). This was significantly lower in Group C when compared to Group A (P = 0.026). The mean GET was 27.8 min for Group A, 27.2 min for Group B and 40.7 min for Group C (P = 0.381). The mean SBTT was 256.4 min for Group A, 256.1 min for Group B and 258.1 min for Group C (P = 0.998). Regarding to the rate of complete examinations, the capsule reached the cecum in 20 patients (100%) in Group A, 16 patients (88.9%) in Group B and 17 patients (89.5%) in Group C (P = 0.312). A definite diagnosis based on relevant small bowel endoscopic lesions was established in 60% of the patients in Group A (12 patients), 44.4% in Group B (8 patients) and 57.8% in Group C (11 patients) (P = 0.587).nnnCONCLUSIONnPreparation with 2 L of PEG before small bowel capsule endoscopy (SBCE) may improve small bowel cleansing and the quality of visualization. Simethicone may further reduce intraluminal bubbles. No significant differences were found regarding GET, SBTT and the proportion of complete exploration or diagnostic yield among the three different cleansing protocols.

Finding the solution for incomplete small bowel capsule endoscopy

AIMnTo evaluate whether the use of real time viewer (RTV) and administration of domperidone to patients with delayed gastric passage of the capsule could reduce the rate of incomplete examinations (IE) and improve the diagnostic yield of small bowel capsule endoscopy (SBCE).nnnMETHODSnProspective single center interventional study, from June 2012 to February 2013. Capsule location was systematically checked one hour after ingestion using RTV. If it remained in the stomach, the patient received 10 mg domperidone per os and the location of the capsule was rechecked after 30 min. If the capsule remained in the stomach a second dose of 10 mg of domperidone was administered orally. After another 30 min the position was rechecked and if the capsule remained in the stomach, it was passed into the duodenum by upper gastrointestinal (GI) endoscopy. The rate of IE and diagnostic yield of SBCE were compared with those of examinations performed before the use of RTV or domperidone in our Department (control group, January 2009 - May 2012).nnnRESULTSnBoth groups were similar regarding age, sex, indication, inpatient status and surgical history. The control group included 307 patients, with 48 (15.6%) IE. The RTV group included 82 patients, with 3 (3.7%) IE, P = 0.003. In the control group, average gastric time was significantly longer in patients with IE than in patients with complete examination of the small bowel (77 min vs 26 min, P = 0.003). In the RTV group, the capsule remained in the stomach one hour after ingestion in 14/82 patients (17.0%) vs 48/307 (15.6%) in the control group, P = 0.736. Domperidone did not significantly affect small bowel transit time (260 min vs 297 min, P = 0.229). The capsule detected positive findings in 39% of patients in the control group and 49% in the RTV group (P = 0.081).nnnCONCLUSIONnThe use of RTV and selective administration of domperidone to patients with delayed gastric passage of the capsule significantly reduces incomplete examinations, with no effect on small bowel transit time or diagnostic yield.

Is It Possible to Predict the Presence of Intestinal Angioectasias

Background and Aim. Angioectasias are the most common vascular anomalies found in the gastrointestinal tract. In small bowel (SB), they can cause obscure gastrointestinal bleeding (OGIB) and in this setting, small bowel capsule endoscopy (SBCE) is an important diagnostic tool. This study aimed to identify predictive factors for the presence of SB angioectasias, detected by SBCE. Methods. We retrospectively analyzed the results of 284 consecutive SBCE procedures between April 2006 and December 2012, whose indication was OGIB, of which 47 cases with SB angioectasias and 53 controls without vascular lesions were selected to enter the study. Demographic and clinical data were collected. Results. The mean age of subjects with angioectasias (70.9 ± 14.7) was significantly higher than in controls (53.1 ± 18.6; P < 0.001). The presence of SB angioectasias was significantly higher when the indication for the exam was overt OGIB versus occult OGIB (13/19 versus 34/81, P = 0.044). Hypertension and hypercholesterolemia were significantly associated with the presence of SB angioectasias (38/62 versus 9/38, P < 0.001 and 28/47 versus 19/53, P = 0.027, resp.). Other studied factors were not associated with small bowel angioectasias. Conclusions. In patients with OGIB, overt bleeding, older age, hypercholesterolemia, and hypertension are predictive of the presence of SB angioectasias detected by SBCE, which may be used to increase the diagnostic yield of the SBCE procedure and to reduce the proportion of nondiagnostic examinations.

Contrast-enhanced ultrasonography for assessment of activity of Crohn's disease: The future?

Dear Sir,nnWe read with particular interest the paper by Paredes et al.1 about the usefulness of contrast-enhanced ultrasonography (CEUS) in the assessment of postoperative recurrence of Crohns disease (CD).nnData from endoscopic follow-up of patients after resection of ileocecal disease have shown that in the absence of treatment the postoperative recurrence rate is about 65–90% within 12 months, so ileocolonoscopy is recommended within the first year after surgery2 where treatment decisions may be affected. However, invasiveness, annoying oral preparation and exclusive assessment of mucosa are limitations to endoscopy, making CEUS …

AIMS65 score: a new prognostic tool to predict mortality in variceal bleeding

Sir,Since upper gastrointestinal bleeding (UGIB) remains a common condition worldwide, efforts are being continuously made to optimize its management and to improve patients’ outcomes. Latest guide...

Capsule Endoscopy Scoring Systems and CRP: Evaluation of Small Bowel Disease Activity in Crohnʼs Disease: P-100

and 28 were male (mean age 47 years). FC was requested for various symptoms including chronic diarrhoea, abdominal pain, abdominal distension and per rectal bleeding. Patients were divided into 3 groups based on clinical practice of gastroenterologist. In the first group only FC was requested initially as a screening test to assess bowel inflammation. 31 patients fell in this group, 21 of 31 had negative FC and no further investigations were done, while 10 of 31 had positive FC (mean 150.3 lg/gm). Out of these 5 had no further investigations as symptoms settled on subsequent clinic visit and 5 went on to have further investigations (Colonoscopy þ/Capsule endoscopy) which were all normal. In the second group patient’s had both FC and colonoscopy requested on initial out-patient review. There were 23 patients in this group. 13 of 23 had normal FC and colonoscopy and no further investigations were done. 2 of 23 had abnormal FC (mean 271.5 lg/gm) and colonoscopy. Both were diagnosed with IBD. 8 of 23 had raised FC (mean 171.25 lg/gm) but a normal colonoscopy. 5 of 8 had no further investigations done while 3 had small bowel investigations which were normal. 1 patient of these 3 was treated for presumed small bowel Crohn’s due to raised FC despite normal capsule endoscopy with good effect. In the third group colonoscopy was the initial investigation of choice and was found to be normal but FC was done later in view of persistent symptoms to look for small bowel inflammation. 18 patients fell in this group. 12 of 18 had normal FC and had no further investigations. 6 of 18 had raised FC (mean 114.33 lg/gm). 3 patients with raised FC had small bowel investigation done and all were normal. CONCLUSION(S): In conclusion FC was beneficial when negative. It provided reassurance to the clinicians and helped avoid invasive investigations. However when FC was positive clinical judgment and patient symptoms dictated the need for further investigations. None of the patients diagnosed with IBD had a negative FC.

P298 Vitamin D status and inflammatory bowel disease – the role in disease activity and quality of life

patients in remission and 86% in active condition reporting fatigue. However patients report that their complaints of fatigue are often not addressed in clinical consultations. To date there are no studies exploring this topic from the clinician’s perspective. This study aimed to gain an understanding of healthcare practitioners’ (HCPs) perception of IBD fatigue as experienced by people with IBD, and to identify the range of methods that HCPs use to assess and manage fatigue. Methods: Descriptive phenomenology was carried out to achieve the aims of the study. Purposive sampling was used to identify a range of professionals (gastroenterologists, IBD nurses, general practitioners, dietitians, psychologists and pharmacists). In-depth semi-structured interviews were conducted with 20 HCPs who work with people with IBD between June and December 2012. Interviews were audio recorded and transcribed verbatim. Colazzi’s seven step framework was used to analyse data. The study was approved by the local university ethics committee. Results: Three main themes and several sub-themes were identified. The main themes were: the phenomenon of fatigue as perceived by HCPs; the impact of fatigue on patients’ lives as perceived by HCPs; and the methods used by HCPs to deal with fatigue. Fatigue was identified as an important, but difficult and often frustrating, symptom to understand. The study participants perceived fatigue as ‘such a complicated and complex thing’. HCPs reported that fatigue impacts on the emotional, private and public aspects of patients’ functioning, however there were very few methods suggested on how to assess and manage the fatigue in a systematic way. Many expressed a desire for better education and a frustration at not being able to help patients more. There was consensus that managing fatigue should be a multi-disciplinary effort, but with little idea of clearly defined roles. Conclusions: Despite fatigue being one of the symptoms most frequently reported by IBD patients, it remains poorly understood by HCPs, who find fatigue challenging and frustrating. There is a need for a systematic and structured assessment and management of this distressing symptom and HCPs should communicate with each other about care for each individual patient. There is a need for an assessment framework and for intervention strategies to be tested. It is essential for multidisciplinary team members to be involved in planning and managing coordinated care of patients reporting fatigue in IBD.

Sa1305 Assessment of Liver Fibrosis in Patients With Chronic Hepatitis B -Diagnostic Accuracy of Four Noninvasive Tests

Background: Liver biopsy remains the gold standard to assess liver fibrosis in chronic hepatitis B (CHB). However, the use of noninvasive methods has emerged in recent years, namely tests based on serum fibrosis markers. The aim of our study was to evaluate the accuracy to predict liver fibrosis in CHB patients using four noninvasive tests: APRI [aspartate aminotransferase/platelet ratio index], AAR [aspartate aminotransferase/alanine aminotransferase ratio], FibroQ (fibro-quotient) and FIB-4. Methods: Forty CHB patients who underwent liver biopsy were included in the study. The patients were divided into two groups according to their METAVIR fibrosis scores (F0-1, no/minimal fibrosis; F2-4, significant fibrosis). Diagnostic accuracy for each test was measured using the area under the receiver operating curve (AUC), followed by calculation of sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPV). Results: The FIB-4 score had the best diagnostic accuracy for significant fibrosis (AUC 0,81, 95% CI 0,661-0,963), followed by APRI (AUC 0,80, 95% CI 0,645-0,954), and FibroQ (AUC 0,72, 95% CI 0,504-0,929). AAR did not have a good accuracy for liver fibrosis (AUC 0,48, 95% CI 0,263-0,698). The optimal cutoff value for FIB-4 was 1 (sensitivity 67%, specificity 77%, PPV 46%, NPV 89%), 0,5 for APRI (sensitivity 78%, specificity 68%, PPV 41%, NPV 91%) and 1,7 for FibroQ (sensitivity 67%, specificity 74%, PPV 43%, NPV 88%). Conclusion: FIB-4, APRI and FibroQ are accessible and useful tools to assess liver fibrosis in patients with CHB.

P-052 YI Vitamin D Status and Inflammatory Bowel Disease—The Role in Disease Activity and Quality of Life

BACKGROUND: Inflammatory bowel disease (IBD), comprising Crohn´s disease (CD) and ulcerative colitis (UC), is a group of debilitating conditions associated with deregulated mucosal immune response to intestinal microorganisms in a genetically susceptible host. Vitamin D is well recognized for its involvement in calcium homeostasis and musculoskeletal health. In addition, vitamin D plays a role in a variety of other systems and pathologies such as the immune response. The aim of this study is to investigate the correlation between disease activity and quality of life, in a cohort of IBD patients, with serum vitamin D levels. METHODS: We conducted a cross-sectional study in ambulatory care IBD patients. Clinical disease activity (Harvey-Bradshaw and Mayo clinical score) and quality of life (Short Inflammatory Bowel Disease Questionnaire—SIBDQ) were assessed through validated questionnaires. Serum 25-hydroxyvitamin D levels were used for vitamin D status, and deficiency was defined as a level less than 30 ng/mL. C-reactive protein (CRP), ferritin, albumin, erythrocyte sedimentation rate (ESR) and hemoglobin levels were correlated with serum 25-hydroxyvitamin D levels. All samples were collected during summer months. Statistical analysis was performed with SPSS versus 18.0 and a P value of less than 0.05 was considered statistically significant. RESULTS: A total of 76 patients were enrolled, 72,4% female with mean age 34 ± 10 years, 19 with UC (25%) and 57 with CD (75%). Average serum 25-hydroxyvitamin D levels were low (all 26 ± 10 ng/mL, UC 30 ± 12,54 ng/mL, CD 24,6 ± 8,04 ng/mL) and there was a statistically significant difference between UC and CD patients (P = 0,032). Hypovitaminosis D was found in 68% of all patients, 58% of UC and 72% of CD patients. A significantly higher proportion of patients with low levels of vitamin D had higher levels of CRP (10,7 versus 4,3 mg/L, P = 0,048). On the other hand, the presence of anemia, low levels of albumin, and higher levels of ferritin and ESR didn´t correlate significantly with lower levels of vitamin D. Mean Harvey-Bradshaw was 2,74 (0–15), mean Mayo clinical score was 1,95 (0–8), mean SIBDQ was 51 for UC patients and 50 for CD patients. Vitamin D deficiency didn’t correlate with clinical IBD activity (CD P = 0.278; UC P = 0.224) or lower levels of quality of life (P = 0.993). CONCLUSIONS: A significantly high percentage of IBD patients had vitamin D deficiency, and this condition was significantly more frequent in CD patients, drawing attention to the need for supplementation. CRP levels trended towards an inverse relationship with vitamin D status. In our study clinical disease activity and quality of life didn’t correlate significantly with lower levels of vitamin D.