Simon Everett

Effects of infliximab therapy on transmural lesions as assessed by magnetic resonance enteroclysis in patients with ileal Crohn's disease☆ , ☆☆ , ★

BACKGROUND AND AIMSnAnti TNF therapy induces mucosal healing in patients with Crohns disease, but the effects on transmural inflammation in the ileum are not well understood. Magnetic resonance-enteroclysis (MRE) offers excellent imaging of transmural and peri-enteric lesions in Crohns ileitis and we aimed to study its responsiveness to anti TNF therapy.nnnMETHODSnIn this multi-center prospective trial, anti TNF naïve patients with ileal Crohns disease and with increased CRP and contrast enhanced wall thickening received infliximab 5 mg/kg at weeks 0, 2 and 6, and q8 weeks maintenance MRE was performed at baseline, 2 weeks and 6 months and assessed based on a predefined MRE score of severity in ileal Crohns Disease.nnnRESULTSnTwenty patients were included; of those, 18 patients underwent MRE at week 2 and 15 patients at weeks 2 and 26 as scheduled. Inflammatory components of the MRE index decreased by ≥2 points and by ≥50% at week 26 (primary endpoint) in 40% and 32% of patients (per protocol and intention to treat analysis, respectively). The MRE index improved in 44% at week 2 and in 80% at week 26. Complete absence of inflammatory lesions was observed in 0/18 at week 2 and 13% (2/15) at week 26. The obstructive elements did not change. Clinical and CRP improvement occurred as early as wk 2, but only CDAI correlated with the MRE index.nnnCONCLUSIONnImprovement of MRE occurs from 2 weeks after infliximab therapy onwards and correlates with clinical response but normalization of MRE is rare.

Pediatric gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) Guideline Executive summary

This Executive summary of the Guideline on pediatric gastrointestinal endoscopy from the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) refers to infants, children, and adolescents aged 0u200a-u200a18 years. The areas covered include: indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; endoscopic management of corrosive ingestion and stricture/stenosis; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease (IBD) have been dealt with in other Guidelines and are therefore not mentioned in this Guideline. Training and ongoing skill maintenance will be addressed in an imminent sister publication.

Pediatric Gastrointestinal Endoscopy: European Society of Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) and European Society of Gastrointestinal Endoscopy (ESGE) Guidelines

This guideline refers to infants, children, and adolescents ages 0 to 18 years. The areas covered include indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography; and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease has been dealt with in other guidelines and are therefore not mentioned in this guideline. Training and ongoing skill maintenance are to be dealt with in an imminent sister publication to this.

Guideline for obtaining valid consent for gastrointestinal endoscopy procedures.

Much has changed since the last guideline of 2008, both in endoscopy and in the practice of obtaining informed consent, and it is vital that all endoscopists who are responsible for performing invasive and increasingly risky procedures are aware of the requirements for obtaining valid consent. This guideline is restricted to GI endoscopy but we cover elective and acute or emergency procedures. Few clinical trials have been carried out in relation to informed consent but most areas are informed by guidance from the General Medical Counsel (GMC) and/or are enshrined in legislation. Following an iterative voting process a series of recommendations have been drawn up that cover the majority of situations that will be encountered by endoscopists. This is not exhaustive and where doubt exists we have described where legal advice is likely to be required. This document relates to the law and endoscopy practice in the UK—where there is variation between the four devolved countries this is pointed out and endoscopists must be aware of the law where they practice. The recommendations are divided into consent for patients with and without capacity and we provide sections on provision of information and the consent process for patients in a variety of situations. This guideline is intended for use by all practitioners who request or perform GI endoscopy, or are involved in the pathway of such patients. If followed, we hope this document will enhance the experience of patients attending for endoscopy in UK units.

Effects of Infliximab Therapy on Transmural Lesions Assessed by MRI Enteroclysis in Patients With Ileal Crohn's Disease: The ACTIF Study

to a change in their management. Findings unrelated to IBD were reported in 14% that warranted further investigations or consultations (including 3 new cancers). Conclusions: Crohns disease of the TI can be missed at ileoscopy either due to skipping of the distal TI or due to disease confined to the intramural portion of the bowel wall. CTE complements ileocolonoscopy in assessing disease activity in patients with Crohns disease.

Endoscopic biliary stenting in irretrievable common bile duct stones: stent exchange or expectant management—tertiary-centre experience and systematic review

Introduction Conventional endoscopic duct clearance may not be possible in up to 10%–15% of common bile duct stones (CBDS). Sphincterotomy and biliary drainage by endoprosthesis have for many years been the mainstay of management in irretrievable stones. Recent years have seen the advent of sphincteroplasty or cholangioscopically-guided electrohydraulic lithotripsy (EHL) permitting duct clearance in majority of cases. However, when bile duct clearance is not possible, options include long-term stenting followed by elective stent exchange (ESE) 6–12 monthly or permanent stent insertion (PSI) in selected cases, but it is not clear which management strategy among ESE and PSI is preferable. Methods and aims A retrospective review of all patients in Leeds Teaching Hospitals NHS Trust who underwent plastic stent insertion for biliary access for difficult CBDS from January 2006 to December 2011 was undertaken. Adult patients with irretrievable CBDS who had plastic stent insertions throughout the follow-up period were included. Patients who underwent PSI and ESE annually were retrospectively reviewed to determine the long-term outcomes. A detailed systematic review was also performed, examining the outcomes of CBDS managed with stents. Results During the study period, 674 patients underwent 1769 biliary-stent-related procedures; of which, 246 patients met our inclusion criteria. 201 patients had subsequent duct clearance. 45 patients were, therefore, included in the final analysis, 28 of whom underwent annual ESEs and 17 PSIs. Patients in the PSI group had higher American Society of Anesthesiologists (ASA) scores compared with the ESE group. In the PSI group, 9/17 patients presented acutely with blocked stents, 5 of whom presented within 12u2005months. 2/9 patients were severely ill and died within a fortnight following the repeat endoscopic retrograde cholangiopancreatography (ERCP). In the ESE group, 4/28 patients had duct clearance in subsequent ERCPs, 1/28 patient presented with a blocked stent, and no biliary-related deaths were observed. The mean numbers of ERCPs performed were 0.52 and 1.95 in the PSI and ESE groups, respectively. Conclusions Over 50% of patients treated with long-term stenting re-presented acutely with stent blockage, though many of these were before 12u2005months, meaning planned stent exchange would not have affected the outcome. Duct clearance using all possible modalities is the preferred option, but where not possible, management with biliary stenting either with elective exchange or permanent stenting remains a possibility for carefully selected patients, though maybe best suited to those with limited life expectancy.

Gastric ulcers: malignancy yield and risk stratification for follow-up endoscopy

Background and study aim: Malignant change can occur in gastric ulcer but guideline recommendations for follow-endoscopy (FU-OGD) are conflicting. This study aims to determine rate of malignancy and need for follow-up for gastric ulcers. Patients and methods: Patients with a first diagnosis of gastric ulcer between January 2012 and September 2013 were studied by analyzing endoscopic assessments, dysplasia, and malignancy yield and the influence of risk factors on the likelihood of benign disease. Results: In a cohort of 432 patients with gastric ulcer (53u200a% male, mean age 65 years) dysplasia or neoplasia were found in 27 (19 adenocarcinomas, 2 cases of dysplasia, 5 lymphomas, 1 melanoma; malignancy yield 6u200a%). Twenty-five (93u200a%) cases were diagnosed on first biopsy. The cancer yield of FU-OGD after initially benign biopsy was 0.9u200a%. Binary logistic regression analysis revealed that endoscopically benign appearance (odds ratio 0.004 95u200a% CI 0u200a–u200a0.576; Pu200a=u200a0.029), benign histology on first biopsy (odds ratio 0 95u200a% CI 0u200a–u200a0.39; Pu200a=u200a0.011) and lower number of ulcers (odds ratio 0.22 (95u200a% CI 0.05u200a–u200a0.99); Pu200a=u200a0.049) were independent predictors of benign disease. All dysplastic and neoplastic cases would have been identified by a combination of initial biopsies plus repeat endoscopy with further biopsies for endoscopically suspicious appearances. Conclusions: In this large cohort 6u200a% of gastric ulcers were found to be malignant, highlighting the need for all gastric ulcers to be biopsied. The cancer yield of FU-OGD after benign biopsies was low. We have demonstrated that the combination of benign index histology and no endoscopic suspicion of malignancy can predict benign disease. We recommend that all gastric ulcers to be biopsied. Risk stratification could potentially reduce need for FU-OGD.

OC-028 High definition white light endoscopy (HDWLE) versus high definition with chromoendoscopy (HDCE) in the detection of dysplasia in long standing ulcerative colitis: a randomised controlled trial

Introduction Patients with ulcerative colitis (UC) have an increased risk for colorectal cancer. The yield of surveillance can be improved by addition of newer endoscopic methods like chromoendoscopy (CE)1and HDWLE when compared to standard definition endoscopy.2There are no studies comparing HDCE and HDWLE. The aim of this trial is to compare the rate of detection of dysplasia in patients with long standing UC with HDWLE compared to HDCE. Method Parallel group randomised controlled trial (clinicaltrials.gov number NCT02138318) in which patients with long standing UC (>10 years) requiring surveillance colonoscopy were randomised to either HDWLE or HDCE (with 0.2% indigo carmine spray). HD scopes (Olympus CF260L or 290L) and processors (Olympus Spectrum CV260 or Elite CV290) and HD monitors were used for all procedures. Time to reach caecum and withdrawal time was recorded. Presence of dysplasia was confirmed by two expert GI histopathologists. Data was analysed according to the number of patients who had dysplastic endoscopic lesions detected (per patient analysis) and also to the number of dysplastic lesions (per lesion analysis). Results In total 53 patients were randomised to HDWLE and 50 to the HDCE arm. Baseline characteristics including duration of disease, bowel preparation, endoscopists, concomitant PSC and previous dysplasia were similar in both arms. A total of 14 dysplastic lesions (1 with high grade and 13 with low grade dysplasia) were detected in 11 patients (22%) in the HDCE arm and 6 dysplastic lesions (all low grade dysplasia) in 5 patients (9.4%) in the HDWLE arm. HDCE was significantly better (p = 0.04) than HDWLE on a per patient basis for the detection of endoscopically visible dysplastic lesions. HDCE (0.26 ± 0.6) detected more dysplastic lesions per-patient than HDWLE (0.12 ± 0.4). Withdrawal time was significantly (p < 0.001) higher in HDCE (21.2 ± 5.8 min) compared to HDWLE (13.6 ± 3.3 min). Conclusion HDCE significantly improves the detection of dysplastic lesions in patients undergoing surveillance endoscopy for UC and should be the procedure of choice in these patients. On average it increases procedure time by 8 min over HDWLE. Disclosure of interest None Declared. References Subramanian V, Mannath J, Ragunath K, Hawkey CJ. Meta-analysis: the diagnostic yield of chromoendoscopy for detecting dysplasia in patients with colonic inflammatory bowel disease. Aliment Pharmacol Ther.2011;33:304–312 Subramanian V, Ramappa V, Telakis E, et.al. High definition versus standard definition endoscopy for detection of dysplasia in colonic inflammatory bowel disease. Inflamm Bowel Dis. 2013;19:350–5

Alcoholic liver disease on the intensive care unit – Outcomes and prognostication:

Background Hospital admissions with decompensated chronic alcoholic liver disease have been increasing, leading to increased pressure on intensive care unit services. We aimed to determine the outcome and prognostic factors for patients with alcoholic liver disease requiring admission to intensive care unit. Methods This was a retrospective study over 5 years (January 2006–December 2010) of all intensive care unit admissions with alcoholic liver disease to either of the two Leeds Teaching Hospitals NHS Trust general intensive care units. A detailed case note review was conducted based on a pre-established proforma. Eighty-two patients included. Primary outcome was hospital mortality. Results The overall intensive care unit and hospital mortality were 46% and 67%, respectively. Hospital mortality in patients successfully discharged from intensive care unit with the intent of recovery remained high at 21%. Variceal bleed was the only indicator that had a mortality <60%. Factors which suggested a poor outcome included sepsis (86% mortality) and hepato-renal syndrome (86% mortality). A Sequential Organ Failure Assessment score of greater than 10 on intensive care unit admission was associated with 97% hospital mortality. Sequential Organ Failure Assessment score increased from a mean of 10.9–12.5 in those that did not survive hospital. Patients with first alcoholic liver disease related admission had poorer outcomes. Conclusion These results are similar to previous studies with no significant improvement in outcomes. Alcoholic liver disease is not a contra-indication to intensive care unit admission but assessment of the individual patient is required. The most appropriate objective factors to guide prognostication are the presenting intensive care unit diagnosis and Sequential Organ Failure Assessment score. First presentation of alcoholic liver disease is not a positive prognostic indicator.

PTH-018 Predicting survival in palliative oesophageal stent insertion

Introduction Self-expanding metal stents (SEMS) are an important treatment modality in palliation of malignant dysphagia, either alone or in addition to chemotherapy or radiotherapy. However, the optimal timing of stent insertion remains uncertain when considering prognosis in advanced malignancy. We present a large single centre experience of patients undergoing SEMS insertion for malignant dysphagia. The aim was to identify risk factors associated with overall and 30 day mortality post-oesophageal stenting. Method All patients receiving an oesophageal stent for palliation of dysphagia in primary oesophageal malignancy between January 2009 and December 2013 in Leeds Teaching Hospitals NHS Trust were included. All devices used were Niti S double covered stents inserted by four experienced practitioners using a combined endoscopic and fluoroscopic procedure. Demographics, tumour site and stage, performance status, Charlson co-morbidity index, dysphagia score, previous oncological therapies and serum albumin and CRP in the week prior to stent insertion were retrieved from electronic patient records. Kaplan-Meier survival estimates and Cox proportional hazards regression were performed to identify risk factors predictive of mortality. Results Among 259 patients (mean age 70.3 (range 32 to 99)), the median post-stent survival was 100 days (95% CI, 87 to 116). 51 patients (20%) died within 30 days of the stenting procedure and 10 patients (4%) died within 7 days. 35 patients (14%) required repeat stenting for tumour overgrowth, stricture or stent migration; the median time to re-stent was 137 days (95% CI, 99 to 175). Serum CRP > 50 was an independent predictor of 30 day mortality (hazard ratio [HR], 3.7; 95% CI, 1.7 to 8.0). Overall post-stent mortality was associated with CRP > 50 (HR, 2.3; 95% CI, 1.6 to 3.2) and albumin < 30 (HR, 1.9; 95% CI, 1.1 to 3.1). Conclusion Our 30 day mortality of 20% is consistent with data published elsewhere (131–25%2), but this study identifies the association of elevated CRP with short-term mortality. This may reflect advanced disease or concurrent infection (such as aspiration pneumonia) and may be a useful guide to optimising timing of stent insertion. Disclosure of interest None Declared. References Homs MY, Steyerberg EW, Eijkenboom WM, et al. Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial. Lancet 2004;364(9444):1497–504 van Heel NC, Haringsma J, Boot H, et al. Comparison of 2 expandable stents for malignant esophageal disease: a randomized controlled trial. Gastrointestinal Endoscopy;76(1):52–8