Nik S. Ding

Systematic review: predicting and optimising response to anti‐TNF therapy in Crohn's disease – algorithm for practical management

Nonresponse and loss of response to anti‐TNF therapies in Crohns disease represent significant clinical problems for which clear management guidelines are lacking.

Prospective population‐based cohort of inflammatory bowel disease in the biologics era: Disease course and predictors of severity

We have previously found high incidence of inflammatory bowel disease (IBD) in Australia. A population‐based registry was established to assess disease severity, frequency of complications, and prognostic factors.

Systematic review with meta-analysis: faecal diversion for management of perianal Crohn's disease

Temporary faecal diversion is sometimes used for management of refractory perianal Crohns disease (CD) with variable success.

Liver stiffness plus platelet count can be used to exclude high-risk oesophageal varices.

Endoscopic screening for high‐risk gastro‐oesophageal varices (GOV) is recommended for compensated cirrhotic patients with transient elastography identifying increasing numbers of patients with cirrhosis without portal hypertension. Using liver stiffness measurement (LSM) ± platelet count, the aim was to develop a simple clinical rule to exclude the presence of high‐risk GOV in patients with Child–Pugh A cirrhosis.

Infliximab vs. adalimumab in Crohn's disease: results from 327 patients in an Australian and New Zealand observational cohort study

Maintenance anti‐tumour necrosis factor‐α (anti‐TNFα) treatment for Crohns disease is the standard of care for patients with an inadequate response to corticosteroids and immunomodulators.

Endoscopic Dilatation of Crohn’s Anastomotic Strictures is Effective in the Long Term, and Escalation of Medical Therapy Improves Outcomes in the Biologic Era

BACKGROUND AND AIMS To investigate the long-term efficacy of endoscopic dilatation of Crohns anastomotic strictures and to identify risk and protective factors associated with the need for repeat dilatation or surgery. METHODS A total of 54 patients who had endoscopic balloon dilatations for anastomotic Crohns strictures between 2004 and 2009, with follow-up until June 2014, were identified from a single tertiary center. The primary end points were repeat dilatation or surgical resection, and the impact of radiology, medical therapy, and endoscopic data on these outcomes was analysed with Cox proportional hazards analysis. RESULTS A total of 151 dilatations were performed on patients with a median age of 52 years [interquartile range (IQR), 46-62 years]. The median duration from the first to the second dilatation was 6 years (IQR, 5-7 years). The median disease duration was 28 years (IQR, 19-32 years). At endoscopy, disease activity was reported in 50/54 (92%) cases, with a median Rutgeerts grading of i2 (range, i0-i4). A median of two (IQR 1-9) dilatations was required, with a time to repeat dilatation of 23 months (IQR 7.2-56.9). Escalation of medical therapy was adopted in 22/54 patients (41% of the study population). On multivariate analysis, only combination therapy (anti-TNFα and immunomodulator) was significantly associated with the (decreased) need for repeated dilatation [hazard ratio (HR) 0.23; 95% CI, 0.07-0.67; p = 0.01]. Anastomotic resections were performed in 10 (18%) patients, with a Rutgeerts score of i4 at initial endoscopic balloon dilatation being associated with this outcome (HR 4.55; 95% CI 1.08-19.29; p = 0.04) on multivariate analysis. CONCLUSION Endoscopic balloon dilatation of Crohns anastomotic strictures is safe and effective in the long term. We demonstrate that active disease predicts for future surgery, while escalation of medical therapy may decrease the need for repeat dilatation.

Systematic review with meta-analysis: the management of chronic refractory pouchitis with an evidence-based treatment algorithm.

Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) is considered the procedure of choice in patients with ulcerative colitis (UC) refractory to medical therapy. The incidence of pouchitis is 40% at 5 years. Ten to 15% of patients with pouchitis experience chronic pouchitis.

The body composition profile is associated with response to anti-TNF therapy in Crohn's disease and may offer an alternative dosing paradigm

Anti‐tumour necrosis factor (TNF)s form a major part of therapy in Crohns disease and have a primary nonresponse rate of 10%‐30% and a secondary loss of response rate of 5% per year. Myopenia is prevalent in Crohns disease and is measured using body composition analysis tools.

Meeting update: faecal microbiota transplantation––bench, bedside, courtroom?

A group of stakeholders met, under the aegis of the British Society of Gastroenterology, to discuss the current landscape of faecal microbiota transplantation (FMT) within the UK and beyond. The meeting covered a wide range of topics, ranging from the practical aspects of establishing an FMT service and regulatory issues relating to its delivery, to research implications and likely future directions. Case report and case series data supportive of the efficacy of FMT as treatment for recurrent/refractory Clostridium difficile infection (CDI) have slowly accumulated over many decades, but randomised trial data supporting its use for this indication were lacking until as recently as 2013.1 There are now a growing number of randomised studies/trials that have consistently demonstrated the much greater efficacy of FMT than that of vancomycin in inducing remission from recurrent/refractory CDI; success from a single FMT is quoted at ≥80%, and for two FMTs as ≥90%.1 FMT appears to be similarly as efficacious for this indication regardless of whether the transplant is delivered via the upper gastrointestinal (GI)1 or lower GI tract.2 ,3 Based on this clinical evidence (along with data supporting the cost effectiveness of FMT in comparison with other treatment strategies),4 FMT has now been accepted as an appropriate treatment option for recurrent/refractory CDI by the National Institute for Health and Care Excellence,5 Public Health England6 and European guidelines.7 There is increasing recognition that a distinctive pattern of alteration of the structure of the gut microbiota (or ‘dysbiosis’) appears to characterise a number of conditions, including inflammatory bowel disease and metabolic syndrome. Although it remains largely unclear as to whether these microbiota changes are a cause of these conditions, consequence or incidental, there is much interest as to whether manipulation of the gut microbiota might be a …

Androgenic‐anabolic steroid drug‐induced liver injury

Bodybuilders and athletes frequently abuse androgenicanabolic steroids (AAS), which have both physiological and metabolic consequences. The prevalence of AAS abuse is increasing, with reported rates of 15–30% in weight trainers in health clubs and gyms. AAS are increasingly being used for their cosmetic benefit, with the number of reported steroid users increasing in the high school population group; approximately 6.6% of year 12 students in America were reported to have taken AAS in 1988. More recent reports estimate rates of 3–12% of male and 0.5–2% of female adolescents. Similar figures have been reported in several countries in Europe, and in Australia and Brazil, with a lifetime prevalence of AAS use between 1% and 6% for high school students, and between 9% and 38% among bodybuilders. This trend has not only resulted in an increase in anabolic-steroid-associated reproductive and endocrine disorders, myocardial hypertrophy, stroke, aggression, and depression, but has also been associated with hepatocellular injury. Due to the illicit nature of AAS and the relative paucity of reported cases, there is little consensus on diagnosis, monitoring or therapy for AAS-induced hepatocellular injury. We report the case of a 46-year-old man who presented to the emergency department with a 3-month history of painless jaundice and weight loss of 9 kg over 3 weeks. He had ceased his AAS use 5 months prior to presentation. He reported nausea, pruritus and anorexia. He had ingested stanozolol (40 mg) and methandrostenolone (40 mg) daily for 2 months, and reported stopping usage 5 months prior to his initial symptoms. There was no other exposure to drugs associated with cholestatic liver injury. There was no history of significant alcohol intake, intravenous drug use or herbal medication intake, and his body mass index was 28.5. Examination revealed jaundice, icterus and a mildly tender right-upper quadrant. There was no encephalopathy, and he was haemodynamically stable. Liver function tests showed a mixed cholestatic and hepatitic pattern, with alkaline phosphatase 295 U/L, gamma glutamyl transpeptidase 114 UL, alanine transaminase 125 U/L and bilirubin of 302 mmol/L (conjugated bilirubin of 127 mmol/L). There was no synthetic dysfunction. Viral and autoimmune serologies were unremarkable. Ultrasound of the liver and computed tomography of the abdomen were normal. A liver biopsy showed intrahepatic cholestasis and occasional necroinflammatory foci, consistent with a drug reaction and proliferation (indicative of stanozolol usage) (Fig. 1). He was commenced on ursodeoxycholic acid treatment, and at week 7 post-discharge, he had complete resolution of his jaundice, and liver function tests and ursodeoxycholic acid was ceased. In the setting of controlled medical use, AAS are rarely associated with jaundice. Abuse of AAS is becoming an increasingly common problem; four out of every five users of AAS have been found to be non-athletes, taking these drugs for cosmetic reasons, with most taking larger doses than previously recorded. 17a-AAS include the compounds methyltestosterone, methandrostenolone, oxymetholone, oxandrolone and stanozolol. Long-term AAS use has been linked to a spectrum of liver injury, such as peliosis, adenoma and hepatocellular carcinoma. Stanozolol is a 17a-AAS that is often misused by athletes and bodybuilders. Druginduced liver injury secondary to AAS usually presents with painless jaundice. The level of jaundice appears to be dose-dependent. The pattern of liver function derangement most often described in association with AAS is a mixed cholestatic and hepatitic picture, which corresponds with the intrahepatic cholestasis and hepatocellular necrosis found in liver biopsy. AAS have been shown in adult male rats to result in moderate inflammatory or degenerative lesions in Figure 1 Necroinflammatory appearance with cholestasis. bs_bs_banner