Johannes Hausmann

Methotrexate for maintenance of remission in chronic active Crohn's disease: Long‐term single‐center experience and meta‐analysis of observational studies

Background: According to current guidelines methotrexate (MTX) should be considered as a second‐line immunomodulator in patients with chronic active Crohns disease (CD) if purine analogs are not tolerated or there is a lack of efficacy. However, its therapeutic role remains controversial to the present day. Methods: Medical records of all eligible patients treated in the outpatient clinic of the Johann Wolfgang Goethe‐University Hospital between December 2000 and January 2009 were reviewed. Results: Sixty‐three patients were identified. The mean duration of treatment was 100 weeks (range, 2–364 weeks) with a mean cumulative dose of MTX of 2130 mg (range, 40–9005 mg). In 50 (79%) patients started on MTX clinical remission could be achieved within 3 months of treatment. The cumulative probability of these patients to maintain remission was 95.3%, 89.5%, 70.6%, and 62.8% at 6 months, 1, 2, and 3 years of treatment, respectively. The respective figures of the meta‐analysis were 94%, 86%, 75%, 53%, and 43. Drug‐related side effects were reported in 50 patients (79%), leading to withdrawal of MTX in 21 cases (33%). Conclusions: Along with previous observations our data demonstrate the efficacy of MTX as a second‐line immunomodulator in chronic active CD. However, its use is limited due to intolerable side effects in a large proportion of patients. The results should encourage further research in order to establish the definite significance of MTX in chronic active CD. (Inflamm Bowel Dis 2010)

Update S3-guideline: “sedation for gastrointestinal endoscopy” 2014 (AWMF-register-no. 021/014)

Prof. Dr. Till Wehrmann Fachbereich Gastroenterologie, DKD Helios Klinik Wiesbaden GmbH Aukammallee 33 65193 Wiesbaden Germany Tel.: ++ 49/6 11/5 77–212 Fax: ++ 49/6 11/5 77–460 twehrmann@hotmail.com This updated guideline (as in the original version in 2008) is published by the Endoscopy Section of the German Society for Gastroenterology, Digestive and Metabolic Diseases (Deutsche Gesellschaft für Gastroenterologie, Verdauungsund Stoffwechselerkrankungen, DGVS), which also has ultimate responsibility for them. Copublishers are the professional associations and organizations that participated in the preparation of this guideline: ▶ German Association of Gastroenterologists in Private Practice (Berufsverband Niedergelassener Gastroenterologen Deuschlands e.V., bng) ▶ Surgical Task Force for Endoscopy and Sonography of the German Society for General and Visceral Surgery (Chirurgische Arbeitsgemeinschaft für Endoskopie und Sonographie der Deutschen Gesellschaft für Allgemeinund Viszeralchirurgie; DGAV) ▶ German Crohn’s Disease/Ulcerative Colitis Association (Deutsche Morbus Crohn / Colitis ulcerosa Vereinigung e.V.; DCCV) ▶ German Society for Endoscopy Assisting Personnel (Deutsche Gesellschaft für Endoskopiefachberufe; DEGEA) ▶ German Society for Anesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e. V.; DGAI) ▶ Society for Legislation and Politics in Health Care (Gesellschaft für Recht und Politik im Gesundheitswesen; GPRG) Coordination and guidance: T. Wehrmann, A. Riphaus, I. Kopp

Pan-intestinal capsule endoscopy in patients with postoperative Crohn's disease: a pilot study

Abstract Background: Patients are at increased risk of disease recurrence after surgical treatment of Crohn’s disease. Endoscopic detection of postoperative, ileo-colonic inflammation is well established, but the potential of pan-intestinal endoscopy is yet unknown. Methods: This prospective multicenter pilot study assessed the value of pan-intestinal capsule endoscopy using a colon capsule endoscope for the detection of inflammatory recurrence of Crohn´s disease. Patients who had been operatively treated for Crohn´s disease were included. Colon capsule endoscopy was performed 4–8 weeks (d1) and 4–8 months (d2) postoperatively together with ileo-colonoscopy at d2 using a modified Ruttgeerts index for evaluating disease activity. Results: Twenty-two patients were included into this study. At d1, significant disease activity (Ruttgeerts index ≥2) was detected in 3/16 (19%) of the patients. At d2, half of the patients (6/12) showed active disease, whereas ileo-colonoscopy revealed significant inflammation in 5/15 (33%). All patients rated as having active disease by ileo-colonoscopy had been revealed by PICE as well. These findings influenced the medical treatment in every case. Conclusion: Pan-intestinal capsule endoscopy seems to be feasible in the postoperative surveillance of Crohns disease. Disease activity is reliably detected. Especially, the findings in the small bowl might be a significant advantage in comparison to ileo-colonoscopy, as they can have significant impact on clinical management. Further studies with a larger number of patients are needed to confirm these findings and might lead to a replacement of the flexible ileo-colonoscopy with pan-intestinal capsule endoscopy in this indication in the future.

The capsule endoscopy “suspected blood indicator” (SBI) for detection of active small bowel bleeding: no active bleeding in case of negative SBI

Abstract Objective. Capsule endoscopy (CE) is the gold standard to diagnose small bowel bleeding. The “suspected blood indicator” (SBI) offers an automated detection of active small bowel bleeding but validity of this technique is unknown. The objective was to analyze specificity and sensitivity of the SBI using the second small bowel capsule generation for the detection of active bleeding. Methods. This is a retrospective analysis of all patients (199) who attended our clinic for CE from June 2008 through March 2013. The second-generation PillCam SB 2 capsule was used for detection of (1) luminal blood content and (2) potentially responsible small bowel lesions. The findings of an independent investigator were correlated to SBI findings and a number of SBI markings were analyzed by a receiver operating characteristic (ROC). Results. In 157/199 cases, no sign of active bleeding or altered blood was detected. One hundred and thirty-seven of these 157 cases provided at least one SBI marking and a mean of 18.4 positive SBI markings per record were found. In 20 cases, neither SBI nor the human investigator detected abnormalities. Thirteen patients showed investigator-detected minor bleeding with mean SBI findings of 36 positive screenshots per record. When major bleeding was diagnosed by the investigator (n = 29), SBI detected a mean of 46.6 SBI-positive markings. SBI turned positive in 179 patients, whereas the investigator detected active bleeding in 42 cases. All patients with active bleeding were detected by SBI (sensitivity 100%, specificity 13%). ROC analysis revealed 51.0 SBI markings being the optimal cutoff for active versus no bleeding (sensitivity 79.1%, specificity 90.4%, misclassification of 15.3%). Conclusion. The new SBI software is a reliable tool to exclude active bleeding and/or major lesions but analysis of the CE video by a trained investigator is still important for the detection of lesions responsible for past bleeding.

Narrow-band imaging vs. high definition white light for optical diagnosis of small colorectal polyps: a randomized multicenter trial.

BACKGROUND AND STUDY AIM The aim of the study was to compare the latest narrow-band imaging (NBI) device with high-definition white light (HDWL) endoscopy for accuracy of real-time optical diagnosis of small colorectal polyps. PATIENTS AND METHODS We conducted a randomized, prospective, multicenter trial at three study sites in Germany. In the NBI arm, endoscopists used NBI for the prediction of polyp pathology on the basis of the NBI International Colorectal Endoscopic classification. In the HDWL arm, NBI was not used for optical classification of polyp histology. The primary outcome was accuracy of optical diagnoses (neoplastic vs. non-neoplastic) in small polyps measuring < 10 mm. Secondary end points included sensitivity and negative predictive value (NPV). RESULTS A total of 380 patients were randomized 1:1 to either the NBI or HDWL arm. A total of 421 polyps measuring < 10 mm were detected (55.8 % neoplastic, 44.2 % non-neoplastic). Accuracy, sensitivity, and NPV were 73.7 %, 82.4 %, and 75.5 %, respectively, in the NBI arm and 79.2 %, 79.8 %, and 73.4 %, respectively, in the HDWL arm (P = 0.225, P = 0.667, P = 0.765). More polyps were assessed with high confidence in the HDWL arm (82.6 %) than in the NBI arm (73.7 %; P = 0.038). The NPV of the prediction of neoplastic histology in diminutive polyps (≤ 5 mm) rated with high confidence was 90.3 % in the NBI arm. We detected significant differences between the participating study sites in the performance data of predictions. CONCLUSION The levels of accuracy for real-time prediction of polyp histology (< 10 mm) did not differ between NBI and HDWL for optical diagnosis. Variation in the performance of optical diagnosis was apparent between study centers. TRIAL REGISTRATION ClinicalTrials.gov (NCT02009774).

Risk factors for early and late procedure-related adverse events in percutaneous endoscopic gastrostomy: A single center, retrospective study: Predictors for adverse events in PEG

Percutaneous endoscopic gastrostomy (PEG) provides the most common method to ensure enteral nutrition for various indications. However, PEG placement may be associated with relevant procedure‐related morbidity and mortality. We aimed to identify clinical parameters predicting an increased risk of PEG‐related adverse events.

Predictive Value of Computed Tomography Scans and Clinical Findings for the Need of Endoscopic Necrosectomy in Walled-off Necrosis From Pancreatitis

Objectives Choosing the best treatment option at the optimal point of time for patients with walled-off necrosis (WON) is crucial. We aimed to identify imaging parameters and clinical findings predicting the need of necrosectomy in patients with WON. Methods All patients with endoscopically diagnosed WON and pseudocyst were retrospectively identified. Post hoc analysis of pre-interventional contrast-enhanced computed tomography was performed for factors predicting the need of necrosectomy. Results Sixty-five patients were included in this study. Forty patients (61.5%) were diagnosed with pseudocyst and 25 patients (38.5%) with WON. Patients with WON mostly had acute pancreatitis with biliary cause compared with more chronic pancreatitis and toxic cause in pseudocyst group (P = 0.002 and P = 0.004, respectively). Logistic regression revealed diabetes as a risk factor for WON. Computed tomography scans revealed 4.62% (n = 3) patients as false positive and 24.6% (n = 16) as false negative findings for WON. Reduced perfusion and detection of solid findings were independent risk factors for WON. Conclusions Computed tomography scans are of low diagnostic yield when needed to predict treatment of patients with pancreatic cysts. Reduced pancreatic perfusion and solid findings seem to be a risk factor for WON, whereas patients with diabetes seem to be at higher risk of developing WON.

Detecting and Managing Small Bowel Crohn's Disease - Capsule Endoscopy Becoming a First Line Diagnostic Method?

Small bowel endoscopy is crucial for diagnosing small bowel Crohn’s disease, and capsule endoscopy is complemented by balloon-assisted enteroscopy to take biopsies and by magnetic resonance imaging to visualize enteral and extra-intestinal involvement. Recently, imaging has also become a key instrument to manage Crohn’s disease patients. Treatment control is advised for patients who have undergone bowel resections and is increasingly used to testify treatment success in non-operated patients, too. In this review we present the modern imaging methods to diagnose and to manage Crohn’s disease with a special focus on the small bowel. Moreover, current knowledge on the impact of diagnostic methods on the patients’ outcome is reported.

Fidaxomicin—The Next Step? A New Narrow-Spectrum Macrocyclic Antibiotic for the Management of Clostridium Difficile Infection

context, Treg cells can be induced by intestinal microbiota products such as the polysaccharide A carbohydrate (Proc Natl Acad Sci U S A 2010;107:12204–12209). Differentiation into Foxp3 Treg cells can be promoted by all-trans retinoic acid (Immunity 2009;30:626–635). Identifying key metabolites derived from beneficial Clostridium species in this study may provide evidence for understanding the regulatory mechanisms of immune systems. As a future perspective, it is also enticing to investigate the role of Clostridium species in colorectal cancer. Experimental ata suggest crucial roles of microbiota in intestinal tumorgenesis (Science 2007;317:124–127), and patients with IBD ave a greater risk of developing colitis-associated colorectal ancer. On the other hand, Treg cells have a definite role in romoting cancer in some organs, and a clinical trial has een performed using anti-CD25 antibody to deplete OXP3 Treg cells (Ann N Y Acad Sci 2009;1174:99–106). herefore, targeting defined Clostridium species that enhance reg cell activity should be carefully applied. In fact, an ndividual with an altered microbiota harboring an abunance of Clostridium species may become more susceptible to enteric infections (Inflamm Bowel Dis 2009;15:1183–1189). Although Bacteroides fragilis can promote CD4 T cells to secrete IL-10 in mice, it opportunistically invades intestinal tissues resulting in infectious diseases in immunocompromised hosts. Thus, the resident intestinal microbial community does not necessarily imply that a particular species has an entirely benign disposition toward its host (Nat Rev Immunol 2010;10:159–169). Although probiotic administration of Clostridium species may be a simple application, understanding the molecular properties that make Clostridium species either proor anti-inflammatory will be an important step for therapeutic applications. Further investigations are required to reveal the details regarding beneficial intestinal microbiota that induces Treg cells.