Manish B. Singla

Hepatitis C eradication with sofosbuvir leads to significant metabolic changes

AIM To assess the effect of sofosbuvir (SOF) based regimens on glycemic and lipid control. METHODS This is a retrospective analysis of hepatitis C virus (HCV)-infected patients treated and cured with a SOF regimen [SOF/ribavirin/interferon, SOF/simeprevir, or SOF/ledipasvir (LDV) ± ribavirin] from January 2014 to March 2015. Patients with hemoglobin A1C (HbA1C) and lipid panels within six months before and six months after therapy were identified and included in our study. Due to the known hemolytic effect of ribavirin, HbA1C was obtained a minimum of three months post-treatment for the patients treated with a ribavirin regimen. Medical history, demographics, HCV genotype, pre-therapy RNA, and liver biopsies were included in our analysis. The patients who started a new medication or had an adjustment of baseline medical management for hyperlipidemia or diabetes mellitus (DM) were excluded from our analysis. RESULTS Two hundred and thirty-four patients were reviewed, of which 60 patients met inclusion criteria. Sixty-three point three percent were male, 26.7% were Caucasian, 41.7% were African American and 91.7% were infected with hepatitis C genotype 1. Mean age was 60.6 ± 6.7 years. Thirty-nine patients had HbA1C checked before and after treatment, of which 22 had the diagnosis of DM type 2. HbA1C significantly decreased with treatment of HCV (pretreatment 6.66% ± 0.95% vs post-treatment 6.14% ± 0.65%, P < 0.005). Those treated with SOF/LDV had a lower HbA1C response than those treated with other regimens (0.26% ± 0.53% vs 0.71% ± 0.83%, P = 0.070). Fifty-two patients had pre- and post-treatment lipid panels; there was a significant increase in low-density lipoprotein (LDL) and total cholesterol (TC) after treatment (LDL: 99.5 ± 28.9 mg/dL vs 128.3 ± 34.9 mg/dL, P < 0.001; TC: 171.6 ± 32.5 mg/dL vs 199.7 ± 40.0 mg/dL, P < 0.001). Pre-treatment body-mass index (BMI) did not differ from post-treatment BMI (P = 0.684). CONCLUSION Eradication of HCV with a SOF regimen resulted in a significant drop in HbA1C and an increase in LDL and TC post therapy.

How to Take Advantage of Mentorship.

Significant resources have been dedicated to training faculty physicians to become better mentors. As I reflect on my three years of fellowship and my time with the ACG Case Reports Journal, I find that mentorship requires significant effort from both the mentor and the mentee. Here are the lessons I have learned on how to take advantage of great mentors:

Esophageal mucosal bridge in a young man with radiation esophagitis.

This is a case of an esophageal mucosal bridge in a patient after radiation therapy and illustrates a unique approach for treatment. A 21-year-old man with Ewing’s sarcoma of the spine had dysphagia and weight loss 2 months after completing radiation therapy. EGD showed a stricture 25 cm from the incisors; this was dilated with a through-thescope balloon to 12 mm. His symptoms resolved initially but returned 2 weeks later. Repeated EGD showed, at 27 cm from the incisors, a stricture 7 mm in diameter. At 29 cm from the incisors, there was a mucosal bridge 1 cm in depth across the lumen (Fig. 1A). This bridge was dissected with argon plasma coagulation at 0.3 L/min and 20 watts (Fig. 1B). The bases of the bridge were injected with a mixture of saline solution and triamcinolone to prevent recurrence (Video 1, available online at www. giejournal.org). His symptoms improved after therapy, and follow-up endoscopy showed resolution of the bridge. Esophageal mucosal bridges are rare. Only 1 previous case of a mucosal bridge has been reported in a patient after

Heart Under Attack: Cardiac Manifestations of Inflammatory Bowel Disease

There is a well-established association between chronic inflammation and an elevated risk of heart disease among patients with systemic autoimmune conditions. This review aims to summarize existing literature on the relationship between inflammatory bowel disease and ischemic heart disease, heart failure, arrhythmia, and pericarditis, with particular attention to approaches to management and treatment.

Infliximab-induced Anterior Uveitis in a Patient with Ulcerative Colitis

Dear Editor, Our patient is a 49-year-old male diagnosed with left-sided ulcerative colitis (UC) in 1992. His symptoms at diagnosis were eight to ten bloody bowel movements daily and associated arthralgias. He required multiple steroid courses for flares and was started on 6-mercaptopurine (6MP) and mesalamine with a partial response. Subsequently, 6MP was discontinued due to drug-induced hepatotoxicity and pancytopenia. He was induced with infliximab 5 mg/kg and dosed every 8 weeks with subsequent resolution of symptoms. In early 2012 he had breakthrough arthralgias between doses, but his bowel symptoms remained in remission. A sigmoidoscopy revealed active colitis and …

Su1345 Vitamin D Malabsorption Is Associated With Tobacco Use and Surgery in Patients With Crohn's Disease

on the 8 point score was r=.64. There was no correlation between shifts in religiosity and IBD symptom scores, or in IBD symptom shift (years 1-4 compared to years 8-10), or with pain scores (SF-36) at years 1-4. IBD symptoms did not drive people to or from religion. Spiritual values gave strength to face everyday difficulties: A lot for 26%, Some for 21%, A little for 20%, Not at all for 32%. Spiritual values helped in understanding the difficulties of life: A lot, 21%; Some, 25%; A little, 21%; Not at all, 32%, Missing, 1%. Doctors were seen as the most important factor in health, with a mean of 4.2 out of 6, followed by self, score of 3.5, fate score of 2.9 and finally God, score of 1.7. Doctor health locus of control correlated with cross-sectional IBDQ bowel symptoms r = -18 (p = .02), Self health locus of control showed a correlation of r = -.16 (p = .04). Conclusions Spirituality was used as a coping strategy but believing that oneself and ones doctors are in charge of health correlated with lower levels of symptoms. Belief that fate or God is in charge is neither good nor bad.

Esophagogastric Fistula Caused by an Angelchik Antireflux Prosthesis

The Angelchik prosthesis is an antireflux device that was popular in the 1980s for treatment of refractory gastroesophageal reflux disease (GERD). We present a patient who developed a gastroesophageal fistula 17 years after Angelchik prosthesis placement. The incidence of late complications continues to grow, and clinicians should consider device malfunction in patients with history of Angelchik placement presenting with abdominal symptoms.

Mo1842 Comparison of Inflammatory Versus Fibrostenotic Phenotype in Eosinophilic Esophagitis

Background: Eosinophilic esophagitis (EoE) is a chronic inflammatory condition which causes esophageal remodeling and stricture formation over time. Aim: To explore the natural course of symptoms, endoscopic findings to include stricture development, and histology in EoE patients. Methods: EoE adult patients (age > 18 years) were prospectively enrolled from databases of two medical centers (Walter Reed and Mayo Clinic Jacksonville). All EoE patients were diagnosed per recent consensus guidelines. All patients completed index and follow-up symptom surveys. Endoscopic features (rings, furrows, plaques, strictures) and histology from index and follow-up endoscopies were recorded. Disease behavior was classified as inflammatory if endoscopic findings demonstrated furrows or white plaques and classified as fibrostenotic if endoscopic findings included rings or strictures. Results: 165 EoE patients were identified, mean age 42 ± 14 years; 88.5% Caucasian and 70% male. Median (range) duration of symptoms prior to EoE diagnosis was 66 months (0.1-425). Median follow-up time was 19.2 months (0.9-120). At index, the majority (124/165, 75%) presented with fibrostenotic EoE and 25% (41/165) presented with inflammatory disease. Patients who presented with a stricture had a significantly longer duration of symptoms prior to diagnosis (130 vs 86 months, p=0.011). Patients with fibrostenotic features had more food allergies than those with inflammatory disease (23.4% vs. 4.9%, p=0.010); otherwise, other allergic conditions were similar. At index endoscopy, significantly more patients with fibrostenotic disease had dense proximal eosinophilia (>15 eos/hpf) than patients with inflammatory disease (81.1% vs. 64.3%, p=0.015), but were similar in degree of distal eosinophilia (86.4% vs. 85.3%, p=0.415). Over time, disease behavior remained unchanged in the majority (87.3%, 144/165) of patients. Of the 41 patients presenting with inflammatory disease, 21 patients (51%) developed fibrostenotic features with 15 of these developing a stricture at follow-up endoscopy. Patients who developed fibrostenosis had more dense eosinophilia on biopsies (proximal 68.4% vs. 20.0%, p=0.015; distal 68.2% vs. 36.8%, p=0.049) than those who maintained inflammatory features. The majority of patients (68%) reported improved symptoms over time regardless of their disease behavior. Conclusions: The majority of patients with EoE present with or develop fibrostenotic disease. Duration of symptoms was significantly greater in patients presenting with stricture. Dense proximal esophageal eosinophilia is associated with the presence of fibrostenosic disease and higher levels of eosinophilia may predict transformation from inflammatory to fibrostenotic disease.

Infliximab Induced Anterior Uveitis in a Patient With Ulcerative Colitis: P-2 YI

Anti-tumor necrosis factor (TNF) therapy is associated with increased infectious risk including reactivation of latent tuberculosis infection (LTBI). It is recommended that patients with risk factors for tuberculosis (TB) be evaluated for LTBI prior to initiation of anti-TNF therapy. Patients with evidence of LTBI undergo treatment before initiation of biologic therapy. The risk of disseminated TB after treatment and initiation of biologic therapy is not well characterized in patients with inflammatory bowel disease. We present a patient who developed disseminated TB as a complication of anti-TNF therapy after completing appropriate treatment for LTBI Case Report: A 52 yo Sri Lankan male with clinical and pathologic evidence of Crohn colitis is found to have asymptomatic LTBI. Treatment with isoniazid (INH) was initiated. After 6 weeks of therapy he was started on infliximab. The patient had a good initial response to therapy but required intermittent prednisone for control of his symptoms. After a viral URI, infliximab was discontinued and not restarted. He completed a 9-month course of INH and was feeling well on no anti-TB treatment. The patients Crohn disease flared and he was initiated on adalimumab after a colonoscopy confirmed active disease. Three months after adalimumab initiation and 4 months after completion of INH for LTBI he had a febrile illness, diarrhea and weight loss. A CT abdomen/pelvis was obtained and showed multiple lesions throughout the spleen and liver. The adalimumab was stopped and he was admitted to hospital for further work-up. After an extensive work-up including evaluation for fungal etiologies and a spleen biopsy he was initiated on empiric anti-TB treatment. After several weeks the AFB smear from both sputum and spleen were positive for pan-susceptible TB. While undergoing treatment for active TB he has been maintained on mesalamine based therapy with marginal control of his Crohn disease. Discussion: Prior to initiation of anti-TNF treatment patients with IBD should be evaluated for active and latent TB1. The risk of disseminated TB after treatment for LTBI and initiation of biologic therapy is unknown. If evidence of LTBI is found, treatment is recommended prior to starting biologic therapy2,3. Recommendations from the ATS and BTS vary from 1-9 months of treatment prior to starting anti-TNF therapy, even though chemoprophylaxis is only effective 70% of the time after 9 months. 4,5 We present the case of a patient with Crohn disease, found to have LTBI and initiated on therapy. After completion of LTBI treatment anti-TNF therapy was instituted. He became ill and was admitted to hospital where he was found to have disseminated TB. Though this patients TB presented after completion of therapy for LTBI most cases of disseminated TB are discovered early in the treatment course of anti-TNF therapy. Close monitoring for reactivation is warranted even if patients have undergone treatment, since treatment is not always effective. We present a case report of a patient with Crohn disease and treated LTBI who developed disseminated disease after completion of treatment and initiation of a biologic agent.