Explore the vast range of titles available.

Total proctocolectomy with ileal pouch-anal anastomosis is the surgical procedure of choice for patients with medically-refractory ulcerative colitis or ulcerative colitis with associated dysplasia. Although most patients after ileal pouch-anal anastomosis experience good functional outcomes, a number of complications may develop. Of the long-term complications, pouchitis is most common. Although most respond to antibiotic treatment, some patients develop chronic pouchitis, leading to substantial morbidity and occasionally pouch failure. In patients with pouchitis who are not responsive to conventional antimicrobial therapy, secondary causes of chronic pouchitis need to be considered, including Crohn's disease of the pouch. In recent years, more literature has become available regarding the medical management of chronic pouchitis and Crohn's disease of the pouch, including the use of newer biologic agents. We herein provide a concise review on inflammatory complications involving the ileal pouch, including a focused approach to diagnosis and medical management.

Background Patients with ulcerative colitis and total abdominal proctocolectomy with ileal pouch-anal anastomosis have a 50% risk of pouchitis and a 5% to 10% risk of chronic pouchitis. Aims The goal of the study was to compare pouch microbiota and stool bile acid composition in patients with chronic pouchitis, chronic pouchitis and primary sclerosing cholangitis, and normal pouch. Methods Patients with ulcerative colitis and ileal pouch-anal anastomosis were recruited from March 20, 2014, to August 6, 2019, and categorized into normal pouch, chronic pouchitis, and chronic pouchitis/primary sclerosing cholangitis groups. Stool samples were subjected to bile acid quantification and 16S rRNA gene sequencing. Statistical comparisons of absolute bile acid abundance and pouch microbiota α-diversity, β-diversity, and taxa abundance were performed among the patient groups. Results A total of 51 samples were analyzed. Both α-diversity (P = .01, species richness) and β-diversity (P = .001) significantly differed among groups. Lithocholic acid was significantly lower in patients with chronic pouchitis/primary sclerosing cholangitis than in those with chronic pouchitis (P = .01) or normal pouch (P = .03). Decreased α-diversity was associated with an increased primary to secondary bile acid ratio (P = .002), which was also associated with changes in β-diversity (P = .006). Conclusions Pouch microbiota α- and β-diversity differed among patients with normal pouch, chronic pouchitis, and chronic pouchitis/primary sclerosing cholangitis. Lithocholic acid level and primary to secondary bile acid ratio were highly associated with pouch microbiota richness, structure, and composition. These findings emphasize the associations between pouch microbiota and bile acid composition in dysbiosis and altered metabolism, suggesting that secondary bile acids are decreased in chronic pouchitis. Lay Summary The α- and β-diversity of the pouch microbiota significantly differed in chronic pouchitis, chronic pouchitis and primary sclerosing cholangitis, and normal pouch. Microbiota changes were associated with stool bile acid composition. Decreased diversity was associated with decreased secondary bile acids.

Abstract Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for patients with medically refractory ulcerative colitis (UC) or indeterminate colitis, UC with colonic dysplasia or neoplasia, and familial adenomatous polyposis. In general, patients experience good function outcomes and quality of life with an IPAA. Although pouchitis is the most well-recognized and frequent complication after IPAA, a number of additional inflammatory, postsurgical, structural, neoplastic, and functional complications may occur, resulting in pouch dysfunction. We herein provide a comprehensive review of pouch function and an approach to diagnosis and management of pouch complications.

INTRODUCTION:Intestinal intussusception is the telescoping of a proximal into an adjacent distal segment of the gastrointestinal (GI) tract. Intussusception is rare in adults, accounting for less than 5% of all mechanical bowel obstructions. Approximately 80-90% of intussusceptions in adults are secondary to an underlying pathological process, including malignant lesions, polyps, or Meckel's diverticulum. Therefore, when intussusception occurs in adults, further investigation to determine the etiology is warranted.CASE DESCRIPTION/METHODS:A 48 year-old female without significant past medical history developed severe, episodic abdominal pain six to eight weeks prior to presentation with associated nausea and occasional emesis. Recent CT scan of the abdomen and pelvis with contrast demonstrated small bowel intussusception in the area of the ligament of Treitz (Figure 1). Laboratory investigations were notable for microcytic anemia. She was referred to gastroenterology and underwent extended esophagogastroduodenoscopy (EGD) which revealed a 4 cm mass in the fourth portion of the duodenum (Figure 2). Initial mucosal biopsy suggested a possible tubulovillous adenoma with low-grade dysplasia. She subsequently underwent surgical resection of the small bowel mass with duodeno-jejunostomy. Surgical pathology revealed a traditional serrated adenoma (TSA) with low-grade dysplasia forming a cluster of polyps ranging from 0.5 to 4.3 cm in size (Figure 3). She did well postoperatively and was discharged on post-operative day 6. She will be undergoing colonoscopy after recovering from surgical intervention.DISCUSSION:Of the three types of serrated adenomas, TSA is the least common, accounting for only 5% of serrated polyps. These are commonly found in the colorectum and have rarely been described in other portions of the GI tract. The first case of TSA of the duodenum was not described until 2004. More recently, TSAs have been detected throughout the upper GI tract. However, reports of TSAs causing small bowel intussusception have not been described. This novel case highlights the importance of considering this in the differential for any adult with proximal small bowel intussusception. Importantly, TSAs of the upper GI tract may represent more aggressive lesions with high malignant potential and should be excised to rule out the possibility of a developing malignancy.

INTRODUCTION:Eosinophilic esophagitis (EoE) and inflammatory bowel disease (IBD) are distinct chronic inflammatory conditions involving the gastrointestinal tract. The presence of eosinophilic infiltration in gastrointestinal mucosa has been observed as a histopathological feature of IBD, being described in both Crohn's disease (CD) and ulcerative colitis (UC). The natural history of patients with coexisting EoE and IBD has not been extensively studied. Our aim was to determine clinical characteristics and treatment outcomes in patients with concomitant IBD and EoE.METHODS:A retrospective cohort study was performed of all EoE patients who also had a diagnosis of IBD from January 2000 to December 2018. Patients were identified using ICD-9 and ICD-10 diagnostic codes. Confirmation of EoE and IBD diagnoses were required for inclusion in the study. Pertinent demographic and clinical data were extracted from the electronic medical record. Treatment outcomes and frequencies of disease-related complications were determined.RESULTS:Sixty-nine patients met inclusion criteria (68.1% male) with a median follow-up of 6 years. Forty-one patients had a diagnosis of CD (59.4%), 26 UC (37.7%), and 2 indeterminate colitis (IC) (2.9%). Forty-eight patients were diagnosed with IBD prior to EoE (69.6%). The most common treatments for EoE were proton pump inhibitors (78.3%) and topical steroids (59.4%) with 51.9% and 63.4% demonstrating clinical improvement, respectively (Table 1). The most common treatments for IBD were oral 5-aminosalicyclic acid (5-ASA) (69.6%), oral corticosteroids (66.7%), azathioprine (44.9%), and adalimumab (43.5%), with 37.5%, 43.5%, 35.5%, and 50% demonstrating clinical improvement, respectively (Table 2). Fifteen patients with CD (36.5%), 7 with UC (26.9%) and 1 with IC (50%) required surgical intervention for IBD. Eighteen patients with CD (43.9%), 8 with UC (30.8%), and 1 with IC (50%) required hospitalization for IBD (Table 3).CONCLUSION:Recent literature has shown an association between IBD and EoE. In our cohort, IBD is the more frequent initial diagnosis. As such, it is important to be vigilant for signs suggestive of EoE in patients with IBD and evaluate accordingly. It seems most patients with IBD and EoE respond to conventional treatment modalities used for each diagnosis. However, about 40% of patients with CD and EoE required hospitalization and/or surgical intervention, possibly suggesting a more severe phenotype in this specific subset of patients.

The clinical characteristics and treatment outcomes in patients with eosinophilic esophagitis (EoE) and inflammatory bowel disease (IBD) have not been extensively investigated. We determined treatment outcomes and frequencies of disease-related complications in patients with EoE and IBD. Among 69 patients who met inclusion criteria, 39 (56.5%) had a diagnosis of Crohn disease. Clinical and histologic response rates to proton pump inhibitors and topical steroids were 25.9% and 24.4%, respectively. Lower than expected clinical and histologic response rates for EoE suggest the combination of EoE and IBD is a medically refractory phenotype with more difficult to treat EoE.

Certolizumab pegol (CZP) has been successfully used for the treatment of Crohn disease (CD); however, real-world data regarding the utility of CZP trough levels (CTLs) are lacking. We aimed to correlate CTL with CD outcomes and to determine frequency of CZP antibodies. Retrospective evaluation of all CD patients on maintenance CZP with CTL obtained between 2016 and 2019. Outcomes included: median CTL, presence of anti-CZP antibodies, biochemical response (BR), clinical response (CR), radiologic response (RR), radiologic healing (RH), and mucosal healing (MH). Seventy-seven CD patients were included. Median CTL was 18.9 µg/mL (interquartile range, 7.6-35.4). Twenty-three patients (27.3%) had positive antibody levels, with lower median CTL compared to patients with no antibodies (0.0 vs 29.8; < 0.0001). Median CTL levels were higher in patients with vs without CR (30.4 vs 10.3 µg/mL; = 0.0015) and RR (29.6 vs 5.8 µg/mL; = 0.006). CZP dosing at least every 2 weeks was associated with higher odds of achieving MH (odds ratio, 3.2; 95% confidence interval, 1.03-9.97). CTL resulted in change in clinical management in 62.7% of cases and presence of CMZ antibodies was associated with an odds ratio of 5.83 (95% confidence interval, 1.57-21.73) of change in management. Receiver operating characteristic curve and quartile analysis suggested that CTL >19 µg/mL is associated with increased rates of CR and RR. Higher CTL was significantly associated with CR and RR. The rate of CZP antibodies was 27.3%. Our data suggest maintenance CTL of ≥19 µg/mL should be achieved in order to optimize outcomes in clinical practice.

BackgroundWe aim to assess the impact of a multidisciplinary inflammatory bowel disease (IBD) conference on the management of patients with complex IBD.MethodsData were collected during each conference from February 2017 through October 2018 with chart review performed at 6 months to determine if conference recommendations were successfully implemented.ResultsEighty-five patients were discussed. The presenting diagnosis was changed by 11.8%. Recommendations for further testing, medical therapy, and surgery were successfully implemented in 77.1%, 98.1%, and 88.4%, respectively.ConclusionsThis study supports the role of IBD multidisciplinary conferences in the management of patients with complex IBD.

Abstract Rituximab (RTX), an anti-CD20 monoclonal antibody used in treatment of hematologic and rheumatologic disease, depletes systemic and intestinal B-cells. Diarrhea is seen in ̴15% of people. Case reports associated RTX with de novo inflammatory bowel disease (IBD). We aim to characterize clinical features and course of RTX-induced colitis. Methods A retrospective cohort study of all patients with new-onset diarrhea after RTX at Mayo Clinic from 01/2006 to 06/2017. Those with diarrhea, concurrent/recent use of RTX in past year, and colon biopsy were included. Diagnosis of IBD or microscopic colitis (MC) before RTX or age<18 were excluded. Demographics, indication of RTX, colitis type and other variables were summarized as median and interquartile range (IQR) or percentage and proportions. Data was analyzed using JMP. Results 460 patients (57% female, median age 57 years [IQR 43-68]) with RTX, diarrhea, and histology were evaluated. Of these, 23 (73.9% female, median age 63 years [IQR 38-72]) were identified RTX-induced colitis (Table 1): 60.8% IBD(8/23 CD, 6/23 UC) and 39.2%MC. Median daily bowel movements was 5 [IQR 3-14]. Most common symptoms along diarrhea were abdominal pain (65.2%) and weight loss (56.5%). Median time from first RTX dose to diarrhea was 20.3 months [IQR 11.3-76.5]. CD19 depletion was noted in all 11 who were tested at time of GI evaluation. Median of 3 months [IQR 4.6-25.2] diarrhea prior to initial GI evaluation. Among those with IBD, 85.7% (12/14) received IBD-directed therapy: 2 biologic monotherapy, 3 immunomodulators, 2 combo (biologic and immunomodulator), 3 5-ASA, and 2 budesonide. 2 required IBD-related surgery. RTX was stopped in 22/23 after diagnosis of RTX-induced colitis with complete improvement in symptoms in 13/22. Conclusion RTX-induced colitis is rare but clinically significant. In our cohort, 5% with new onset diarrhea after RTX who underwent endoscopic evaluation had colitis. Diarrhea resolved in 60% after stopping RTX.