Joanna Law

The use of infliximab for treatment of hospitalized patients with acute severe ulcerative colitis.

BACKGROUND/AIMnThe use of infliximab in severe ulcerative colitis (UC) is established; however, its role in severe acute UC requires clarification. The present multicentre case series evaluated infliximab in hospitalized patients with steroid-refractory severe UC.nnnMETHODSnPatients from six hospitals were retrospectively evaluated. Data collection included demographics, duration of disease and previous treatments. The primary end point was response to in-hospital infliximab; defined as discharge without colectomy.nnnRESULTSnTwenty-one patients (median age 26 years) were admitted between May 2006 and May 2008 with severe UC requiring intravenous steroids and given infliximab (median time to infusion eight days). Sixteen (76%) patients were discharged home without colectomy; three of these underwent colectomy at a later date. Of the remaining 13 patients (62%), all but two did not require further courses of steroids; six patients had infliximab as a bridge to azathioprine and seven patients were maintained on regular infliximab. Five patients required in-hospital colectomy after the initial infliximab.nnnCONCLUSIONSnIn this real-life experience of infliximab in patients with steroid-refractory severe UC, infliximab appears to be a viable rescue therapy. The majority of patients were discharged without surgery and 62% maintained response either as a bridge to azathioprine or maintenance infliximab.

Diagnostic yield of repeat capsule endoscopy and the effect on subsequent patient management.

BACKGROUNDnCapsule endoscopy (CE) has been shown to produce a high diagnostic yield in patients with obscure gastrointestinal bleeding (OGIB); however, in those with negative studies, management is controversial. Very few studies have reported on repeat CE in the same patient; data regarding this diagnostic strategy are limited.nnnOBJECTIVEnTo determine the diagnostic yield of repeated CE studies and how this yield affects subsequent patient management.nnnMETHODSnA retrospective chart review of all patients who underwent CE at St Pauls Hospital (Vancouver, British Columbia) between December 2001 and June 2009 was conducted. Patients who underwent subsequent repeat CE were identified and divided into one of four subgroups. Findings were classified as positive or negative.nnnRESULTSnEighty-two of 676 patients underwent more than one CE study. Group 1 (incomplete study) included 22 patients (27%) and yielded 10 positive findings (45%). Group 2 (screening) comprised four patients (5%) and yielded two positive findings (50%). Group 3 (ongoing symptoms despite previous negative study) totalled 26 patients (32%) and yielded 10 positive findings (38%). Group 4 (previous positive study with treatment/investigation) included 30 patients (37%) and yielded 23 positive findings (77%). Overall, the present study found positive findings in 55% (45 of 82) of repeated CE cases, which resulted in a change in management in 39% (n=32) of the patients.nnnCONCLUSIONnDue to the high diagnostic yield and noninvasive nature of CE, repeat CE appears to be of benefit and should be considered for specific patients before other types of small bowel studies.

Diagnostic yield of capsule endoscopy in the setting of iron deficiency anemia without evidence of gastrointestinal bleeding

BACKGROUNDnThe diagnostic yield of capsule endoscopy (CE) in the setting of iron deficiency anemia (IDA) without evidence of occult⁄overt bleeding has been questioned. Often, these patients have nongastrointestinal causes of iron deficiency but undergo CE to exclude a potential small bowel source.nnnOBJECTIVEnTo assess the diagnostic yield of CE, the characteristics predicting positive results, the presumed etiology of IDA in negative⁄normal CE and patient management after CE.nnnMETHODSnA retrospective review of 934 patients who underwent CE between December 2001 and February 2010 was conducted. All patients had undergone previous negative endoscopic examinations before CE. Patients with IDA but no evidence of overt⁄occult bleeding were separated into three categories based on CE findings: group A - positive; group B - negative⁄normal; and group C - incomplete⁄indeterminate.nnnRESULTSnA total of 101 capsules in 97 patients were evaluated. Group A had 25 subjects with positive findings on CE, 18 of whom were managed supportively. Group B consisted of 69 subjects with negative⁄normal CE, 60 of whom were treated supportively. Group C consisted of three subjects with incomplete CE results.nnnCONCLUSIONnIn patients with IDA without evidence of gastrointestinal bleeding, CE had a low diagnostic yield (25.7%), which increased to 45.5% after adjusting for low dietary iron intake and menorrhagia. However, CE did not alter management in most patients regardless of findings, and many of the lesions requiring intervention were within reach of standard endoscopes. No predictor of positive results was found. In this patient population, careful history taking and thorough endoscopy could improve CE utilization, although its value is still relatively limited.

All that bleeds is not infliximab-refractory ulcerative colitis.

The role of biological agents in moderate to severe ulcerative colitis has been shown to be effective in the induction of clinical remission. However, the role of infliximab therapy for induction of remission in patients with fulminant colitis is debatable. A case of a hospitalized patient with a new diagnosis of severe ulcerative colitis refractory to intravenous steroids is presented. The patient was treated with infliximab and discharged with clinical remission, but subsequently presented back to hospital with a lower gastrointestinal hemorrhage.

Predictors for Positive Outcomes in Capsule Endoscopy for the Indication of Obscure Gastrointestinal Bleeding

Predictors for Positive Outcomes in Capsule Endoscopy for the Indication of Obscure Gastrointestinal Bleeding Jaber Al Ali, Victor Wong, Joanna Law, Henry Chung, Harry Dhaliwhal, Stacey Shapira, Eric Lam, Robert Enns Introduction: Capsule endoscopy (CE) is primarily used for visualization of the small bowel mucosa in patients with obscure gastrointestinal bleeding. The yield of positive findings will depend on the patient group selected for evaluation. Theoretically, careful patient selection will improve the diagnostic yield, thereby maximizing resource utilization. The purpose of this study is to determine if there are any risk factors or patient characteristics that can help predict which patients are likely to have positive findings before undergoing capsule endoscopy. Methods: Risk factors and patient characteristics were identified and multivariable logistic regression was employed for the factors associated with a positive capsule study. Among the factors analyzed (using a prospectively collected database) were indication for procedure, comorbidities, history of NSAIDs, alcohol, smoking, antiplatelet or other anticoagulants, use of a proton pump inhibitor, steroid use, use of SSRI, presence of abdominal pain, change in bowel pattern, presence of red blood per rectum, history of melena, number of previous endoscopies, presence of other forms of small bowel imaging and transfusion requirements prior to the procedure. Results: This study involved a single centre Canadian assessment of 306 patients who underwent CE between 12/01 and 11/05 for the indication of obscure bleeding (overall positive yield 55%). The patients ranged from 18 95 years of age (mean age of 64.8 yr). For the investigation of obscure GI bleeding, the transfusion requirements prior to the capsule endoscopy of O10 units had an OR Z 2.90 (95% CI 1.33 6.30) and the use of between 6 10 units had an OR Z 2.52 (95% CI 1.09 5.8). The presence of diabetes was associated with a negative capsule study OR Z 0.46 (95% CI 0.22 0.95). There was a trend towards a positive capsule study in patients using oral steroids OR Z 3.53 (95% CI 0.86 14.4). Conclusion: Unlike other studies, we have found that very few factors are associated with a positive capsule study in the setting of obscure GI bleeding. The yield in overt and occult bleeding was similar; only those patients who need large transfusion requirements were more likely to have sources of blood loss identified by CE. The presence of diabetes was negatively correlated with identifying a bleeding source in the small bowel; we postulate that these patients may be more likely to have anemia for other reasons.