Kamal V. Patel

Patient optimization for surgery relating to Crohn's disease

The majority of patients with Crohns disease require abdominal surgery during their lifetime, some of whom will require multiple operations. Postoperative complications are seen more frequently in patients requiring abdominal surgery for Crohns disease than in patients requiring abdominal surgery for other conditions. In this article, we review the evidence supporting preoperative optimization, discussing strategies that potentially improve surgical outcomes and reduce perioperative morbidity and mortality. We discuss the roles of adequate cross-sectional imaging, nutritional optimization, appropriate adjustments of medical therapy, management of preoperative abscesses and phlegmons, smoking cessation and thromboembolic prophylaxis. We also review operation-related factors, and discuss their potential implications with respect to postoperative complications. Overall, the literature suggests that preoperative management has a major effect on postoperative outcomes.

Hair Loss in Patients with Inflammatory Bowel Disease

Background: Little is known about the prevalence, causes, and management of hair loss in patients with inflammatory bowel disease (IBD). Despite the fact that there are relatively few case reports describing hair loss in IBD, anecdotally, it is a common clinical problem. Hair loss is associated with both acute and chronic illness, with nutritional deficiencies, and with adverse drug reactions, all of which are relevant to IBD. Methods: A literature search was performed using PubMed from 1966 to July 2012 to identify all articles describing cases of and/or the cause of hair loss in patients with IBD. Results: There is relatively little data describing the prevalence, cause, or course of hair loss in people with IBD. Because there are many potential reasons for hair loss in people with IBD, identifying the cause is not always possible. Telogen effluvium associated with acute or chronic flares of IBD is probably the commonest cause of disease-related hair loss, although the prevalence of this is unknown. Other causes include drug side effects and nutritional deficiencies. More recently shared genetic risk factors with alopecia areata and IBD have been identified. Conclusions: The potential causes of hair loss in IBD are protean, although its prevalence is unknown. A practical guide to assessing and managing patients with hair loss in IBD is presented.

Budd-Chiari syndrome: investigation, treatment and outcomes.

Budd–Chiari syndrome is a rare disorder characterised by hepatic venous outflow obstruction. It affects 1.4 per million people, and presentation depends upon the extent and rapidity of hepatic vein occlusion. An underlying myeloproliferative neoplasm is present in 50% of cases with other causes including infection and malignancy. Common symptoms are abdominal pain, hepatomegaly and ascites; however, up to 20% of cases are asymptomatic, indicating a chronic onset of hepatic venous obstruction and the formation of large hepatic vein collaterals. Doppler ultrasonography usually confirms diagnosis with cross-sectional imaging used for complex cases and to allow temporal comparison. Myeloproliferative neoplasms should be tested for even if a clear causative factor has been identified. Management focuses on anticoagulation with low-molecular-weight heparin and warfarin, with the new oral anticoagulants offering an exciting prospect for the future, but their current effectiveness in Budd–Chiari syndrome is unknown. A third of patients require further intervention in addition to anticoagulation, commonly due to deteriorating liver function or patients identified as having a poorer prognosis. Prognostic scoring systems help guide treatment, but management is complex and patients should be referred to a specialist liver centre. Recent studies have shown comparable procedure-related complications and long-term survival in patients who undergo transjugular intrahepatic portosystemic shunting and liver transplantation in Budd–Chiari syndrome compared with other liver disease aetiologies. Also, the optimal timing of these interventions and which patients benefit from liver transplantation instead of portosystemic shunting remains to be answered.

Lack of effect of Maraviroc intensification on blood and gut reservoir

We show that intensification of treatment with maraviroc in patients chronically infected with HIV-1 receiving successful long-term antiretroviral therapy was not associated with improvements in HIV-related morbidity, HIV reservoir, microbial translocation, immune activation, or immune exhaustion in either gut or peripheral blood. The measurement of reservoir in both gut and blood longitudinally contributes to a paucity of data in the area.Abstract We show that intensification of treatment with maraviroc in patients chronically infected with HIV-1 receiving successful long-term antiretroviral therapy was not associated with improvements in HIV-related morbidity, HIV reservoir, microbial translocation, immune activation, or immune exhaustion in either gut or peripheral blood. The measurement of reservoir in both gut and blood longitudinally contributes to a paucity of data in the area.

Rare case of severe cholangiopathy following critical illness.

Secondary sclerosing cholangitis is a rare condition caused by disorders directly damaging the biliary tree. We present a case of a 34-year-old man with no pre-existing hepatobiliary disease who developed significant cholestasis and subsequent cholangitis while in the intensive care unit for multiorgan failure secondary to H1N1 influenza A (swine flu). After discharge from the intensive care unit, jaundice, fevers, abdominal pain, pruritus and ongoing cholestasis persisted, consistent with recurrent cholangitis. Secondary sclerosing cholangitis was confirmed by liver biopsy and endoscopic retrograde cholangiopancreatography. This is a case of the recently described syndrome of secondary sclerosing cholangitis following critical illness, with associated severe hypoxic and ischaemic injury. He subsequently developed recognised complications of sclerosing cholangitis, including fat-soluble vitamin deficiencies, recurrent cholangitis and liver fibrosis. To the best of our knowledge, this is the first reported case of secondary sclerosing cholangitis following critical illness in the UK.

Diffuse Large B-Cell Lymphoma Recurrence Complicating Primary Intestinal Lymphangiectasia

m p l A man presented with abdominal pain, diarrhea, and 6-kg weight loss. His medical history included priary intestinal lymphangiectasia (PIL), which was diagnosed hen he was 6 years old. Three years ago, he presented with similar symptoms that ere investigated with computed tomography scan of abdomen Figure A; marked mural thickening in multiple small bowel oops and moderate ascites) and small bowel meal (Figure B; iffuse mucosal fold thickening, increased nodularity in muliple small bowel loops, and tiny nodules representing dilated acteal vessels in the lamina propria), with findings typical for ymphangiectasia. Gastroscopy and ileocolonoscopy were performed. Duodenal iopsies showed dilated lymphatic channels characteristic for ymphangiectasia. Terminal ileum biopsies confirmed multifoal diffuse large B-cell lymphoma (DLBCL). Clinical remission as achieved with multiple cycles of rituximab, cyclophosphmide, doxorubicin, vincristine, and prednisolone. Parenteral utrition was required during chemotherapy. Annual surveilance with positron emission tomography– computed tomograhy (PET-CT) up to representation confirmed remission of LBCL. At this presentation, PET-CT showed multiple foci of inreased metabolic activity within the proximal small bowel. astroscopy showed numerous smooth soft cystic lesions inerspersed with whitish spotty lesions in the duodenum (Figure ). Endoscopic appearances and biopsies confirmed these alost entirely replaced the duodenal folds, which was consistent ith lymphangiectasia. To exclude DLBCL recurrence, enterosopy was performed, revealing lymphangiectasia from the dudenum to the proximal jejunum. The jejunum was interpersed with more suspicious-looking lesions (Figure D), with iopsies confirming relapse of DLBCL. Salvage chemotherapy was commenced with rituximab, ytarabine, cisplatin, and dexamethasone. PET-CT confirmed

Video capsule endoscopy for the investigation of the small bowel: primary care diagnostic technology update

#### Clinical Question How effective is video capsule endoscopy in investigating the small bowel compared to traditional investigations? Video capsule endoscopy (VCE) was first developed in 1999 and has been in widespread use since the late 2000s. It is primarily used for investigation of the small bowel and has the advantage of being able to accurately examine the small bowel which cannot be easily reached by standard endoscopy methods. The major advantages are that it is non-invasive, safe, and convenient for the patient, and involves no ionising radiation. Additionally, VCE can provide some information on the rest of the gastrointestinal (GI) tract as well as basic information on small bowel transit time. Previously the small bowel could only be imaged by contrast small bowel studies (for example, barium/gastrograffin) and more recently by cross-sectional imaging such as computed tomography (CT) and Magnetic resonance imaging (MRI). CT and contrast small bowel meal are relatively insensitive for examining the small bowel. Small bowel ultrasound, CT enterography/enterocolysis and MRI enterography/enterocolysis are readily available and can be performed to visualise the small bowel, but requires a radiologist with specialist experience for interpretation of the results. CT has the limitation of exposure to ionising radiation. Available examinations to investigate the small bowel mucosa are by anterograde, that is, per oral push enteroscopy, single/double balloon enteroscopy, and retrograde, that is, per rectum ileoscopy, however, these are not widely available, invasive, and are technically challenging. However, these investigations do allow therapy such as the treatment of angiodysplasia and small lesion removal where necessary. They are generally reserved for cases where non-invasive investigation has confirmed an abnormality. Disadvantages of VCE are that therapeutic work cannot be performed and biopsies cannot be obtained. New developments in VCE have led to new capsules which can be used …

Alopecia areata: A possible extraintestinal manifestation of Crohn's disease

Dear Sir, Protic et al.1 and Ganzetti et al.2 report cases of alopecia areata (AA) in individuals with Crohns disease (CD), discuss the shared molecular pathways, and comment that AA could be considered an extraintestinal manifestation of CD. We would like to highlight other cases of AA in association with CD, as well as with ulcerative colitis which have been reported in the literature, several of which also presented …

OC-045 Faecal microbiota transplantation: implementing a new treatment for recurrent/refractory clostridium difficile infection using banked stool in a tertiary uk centre

Introduction Faecal microbiota transplantation is an effective treatment for recurrent/refractory Clostridium difficileinfection (CDI). A randomised controlled trial reported sustained response in greater than 90% of patients, with an excellent safety profile. NICE approved the treatment as of March 2014. We introduced this new service in January 2015, setting up a stool bank to treat patients with recurrent CDI. We describe the process of initiating this service. Method Stool donors are recruited from non-clinical members of hospital staff or patient selected donors. Donors must be healthy with a BMI <30, not taking oral medication, not received antibiotics in the previous 3 months and not be infected or at risk of any blood-borne viruses or transmissible infectious diseases. Donors are screened for diseases including Hepatitis A, B, C, E, HIV, HTLV, syphilis, CMV, EBV, Entamoeba histolytica, Strongyloides sterocaralis, Cryptosporidium, Giardia, C.difficile, H. Pylori, Norovirus, Campylobacter, Salmonella, Shigella, E.coli O:157, MRSA and multi-drug resistant coliforms. All transplant material has a batch number allowing full traceability. After screening, donors can provide stool for transplant for up to 3 months. >50 g of fresh donated stool is diluted with 250 mls 0.9% normal saline and 12.5% glycerol, filtered to remove large particles and immediately frozen at –800C. Frozen stool can be stored for up to 6 months, offers the benefit of being available on demand, and is as effective as freshly used stool. Recipients are informed of the risks of colonoscopy and the risk of acquiring an unrecognised transmissible disease. Standard bowel preparation is given and the transplant is delivered through the endoscope channel with 75% of the donor stool placed in the caecum, and the remainder in the right colon. Alternatively, infusion can be performed via a nasoduodenal tube. Results This pathway has been successfully implemented. Procedures are performed at the end of a list to allow subsequent deep cleaning of the endoscopy room, and donor stool is available in an ice box 30 min prior to procedure. Individuals are discharged home the day after the procedure, and contacted a week later to ascertain improvement in symptoms, and at 3-months for a second assessment including laboratory testing for C. difficile. Preliminary experience is promising with 100% of patients achieving clinical remission within a week of a single procedure. Conclusion Introduction of a faecal transplant service for CDI is feasible. As with all new treatments safety is paramount. Thorough screening of donors, traceability of transplants and long term follow up is essential. Disclosure of interest None Declared.

Sa1255 Higher Red Blood Cell Methotrexate Polyglutamates Correlate With Increased Disease Activity, and Are Useful in Assessing Adherence

Introduction Methotrexate (MTX) is commonly used in patients with inflammatory bowel disease (IBD). Within red blood cells (RBC), MTX is activated by sequential addition of glutamic acid residues to form polyglutamates (MTXPG 1–5 ). In rheumatoid arthritis, low [MTXPG] has been associated with active disease, whereas other studies have demonstrated an inverse relationship, including the only published data in IBD. The aim of this study was to determine if RBC [MTXPG] reflect clinical response in IBD patients and whether they are useful in assessing adherence. Methods This was a single-centre, retrospective pilot study of 21 IBD patients treated with weekly MTX. RBC MTXPG 1–5 was measured using high-performance liquid chromatography. Clinical status (active disease or remission) was assessed by 2 IBD physicians blinded to [MTXPG], using a combination of prospectively recorded clinical activity indices (Simple Colitis Activity Index, Harvey Bradshaw Index), endoscopy, faecal calprotectin and C reactive protein (CRP). Pearson correlation coefficient, r was calculated to assess the relationship between MTX dose and [MTXPG]. Association between [MTXPG] and clinical response was analysed with unpaired t-test. Results 4/21(22%) patients (3 of whom admitted non-adherence) had undetectable MTXPGs and were excluded from further analysis. MTXPG 2–4 were detected in all adherent patients. PG 3 was the predominant polyglutamate accounting for a mean of 43% of total MTXPG. A linear relationship between dose of MTX and PG 1–5 was observed. 12/21(57%) patients were assessed as having active disease. No significant difference in mean [MTXPG n ] was observed between those with active disease and remission. For each MTXPG n , a non-significant trend towards a higher concentration was observed in patients with active disease. Conclusion In this study, the largest to date in IBD, measuring RBC MTXPG was useful in assessing adherence to MTX. A trend towards higher PG concentrations was associated with active disease confirming the findings in the only other study in IBD. Whether this is confounded by higher doses being used in patients with more active disease warrants further study in larger, prospective trials. Reference Disclosure of Interest None Declared.