International journal of organ transplantation medicine, 2010
Recurrence of hepatitis C virus (HCV) infection following orthotopic liver transplantation (OLT) ... more Recurrence of hepatitis C virus (HCV) infection following orthotopic liver transplantation (OLT) is universal. There is paucity of data on the safety and efficacy of interleukin (IL)-2 receptor antagonist (IL-2RA) when added to the standard immunosuppression regimen in OLT recipients with recurrent HCV infection. To evaluate the efficacy of IL-2RA (Basiliximab) in preventing acute cellular rejection (ACR) in patients with recurrent HCV infection after OLT and to assess the impact of IL-2RA in promoting fibrosis progression in post-OLT recurrent HCV infection. Using an electronic pathology database, we identified all OLT/HCV patients with at least 2 post-OLT liver biopsies (1998-2006). Standard immunosuppression consisted of steroids and calcineurin inhibitor with and without mycophenolate mofetil. All patients who were transplanted after May 2004 received IL-2RA induction therapy. The Ludwig-Batts system was used to stage all biopsies (593 biopsies from 124 patients). The first biop...
Introduction: Anti-glycan antibodies are a promising tool for differential diagnosis and disease ... more Introduction: Anti-glycan antibodies are a promising tool for differential diagnosis and disease stratification of patients with Crohn's disease (CD). We longitudinally assessed level and status changes of anti-glycan antibodies over time in individual CD patients as well as determinants of this phenomenon. Methods: 859 serum samples derived from a cohort of 253 inflammatory bowel disease (IBD) patients (207 CD, 46 ulcerative colitis (UC)) were tested for the presence of anti-laminarin (Anti-L), anti-chitin (Anti-C), anti-chitobioside (ACCA), antilaminaribioside (ALCA), anti-mannobioside (AMCA) and anti-Saccharomyces cerevisiae (gASCA) antibodies by ELISA. All patients had at least two and up to eleven serum samples taken during the disease course. Results: Median follow-up time for CD was 17.4 months (Interquartile range (IQR) 8.0, 31.6 months) and for UC 10.9 months (IQR 4.9, 21.0 months). In a subgroup of CD subjects marked changes in the overall immune response (quartile sum score) and levels of individual markers were observed over time. The marker status (positive versus negative) remained widely stable. Neither clinical phenotype nor NOD2 genotype was associated with the observed fluctuations. In a longitudinal analysis neither changes in disease activity nor CD behavior led to alterations in the levels of the glycan markers. The ability of the panel to discriminate CD from UC or its association with CD phenotypes remained stable during follow-up. In the serum of UC patients neither significant level nor status changes were observed. Conclusions: While the levels of anti-glycan antibodies fluctuate in a subgroup of CD patients the antibody status is widely stable over time.
BackgroundNonalcoholic steatohepatitis (NASH), the most severe form of nonalcoholic fatty liver d... more BackgroundNonalcoholic steatohepatitis (NASH), the most severe form of nonalcoholic fatty liver disease (NAFLD), is associated with inflammation and increased oxidative stress. The neutrophil/lymphocyte ratio (N/L) integrates information on the inflammatory milieu and physiological stress.AimsThe aim of this study was to determine the utility of N/L ratio to predict the presence of NASH in patients with NAFLD.MethodsOur cohort consisted of 101 consecutive patients undergoing liver biopsy for clinical suspicion of NAFLD. Patients were divided into two groups: NASH group (n = 50) and not NASH group (n = 51). The stage of fibrosis was measured using a 4‐point scale. The total white cell count, neutrophil and lymphocyte counts were recorded, and the N/L ratio was calculated.ResultsThe mean age was 49.5 (±10.8) years and the mean BMI was 31.4 (±4.9) kg/m2. Patients with NASH had a higher N/L ratio compared with patients with not NASH [2.5 (1.9–3.3) and 1.6 (1.2–2.0), respectively, P <...
Nonalcoholic fatty liver disease (NAFLD) encompasses a spectrum of disease from simple steatosis ... more Nonalcoholic fatty liver disease (NAFLD) encompasses a spectrum of disease from simple steatosis to steatohepatitis, to fibrosis and cirrhosis. The paediatric NAFLD fibrosis index (PNFI) and transient elastography (TE) are potential noninvasive markers for fibrosis. To prospectively evaluate the performance of PNFI and TE in assessing clinically significant fibrosis in children with biopsy-proven NAFLD. Our cohort consisted of 67 consecutive children with biopsy-proven NAFLD. The stage of fibrosis was scored according to the Nonalcoholic Steatohepatitis Clinical Research Network. Fibrosis ≥ 2 was considered clinically significant. PNFI was calculated using age, waist circumference and triglycerides. TE was performed using the Fibroscan apparatus. Ten patients had fibrosis stage 2-3 and 57 patients had stage 0-1. Both PNFI and TE values were significantly higher in patients with significant fibrosis (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). The area under the receiver operating characteristic (ROC) curve for predicting significant fibrosis of PNFI and TE were 0.747 and 1.00 respectively (P = 0.005). The combined use of PNFI and TE could predict the presence or absence of clinically significant fibrosis in 98% of children with NAFLD. In children with NAFLD, the combination of PNFI and TE can be used to accurately assess the presence of clinically significant liver fibrosis. This will help to identify patients who should undergo liver biopsy because the confirmation of advanced fibrosis would lead to closer follow-up and screening for cirrhosis-related complications.
Background: Literature on endoscopic dilation of Crohn's disease (CD) strictures, especially for ... more Background: Literature on endoscopic dilation of Crohn's disease (CD) strictures, especially for primary (non-anastomotic) strictures is limited. Methods: A historical cohort study was performed on patients who underwent endoscopic stricture dilations for CD in our IBD center. Primary endpoint was the efficacy of first endoscopic dilation in preventing the need for surgery in primary strictures compared to anastomotic strictures. Cox proportional hazards models using robust sandwich covariance matrix estimate were used to evaluate the need for surgery and any further endoscopic intervention. Results: In our study cohort (mean age 42.2 ± 13.1 years, 57% females, 16.4% current smokers, and median follow-up 1.8 years), 128 patients underwent a total of 430 endoscopic stricture dilations for 169 strictures (88 primary, 81 secondary). Forty-two patients (32.8%) required surgery in the follow-up period, with a mean interval period between first dilation and surgery of 33 months. There was no difference between primary or anastomotic strictures with respect to
Background and aim: Crohn's disease (CD) is associated with primary sclerosing cholangitis (PSC).... more Background and aim: Crohn's disease (CD) is associated with primary sclerosing cholangitis (PSC). The aim of the study was to study the association between the severity of PSC and clinical outcome of CD, comparing the course of CD in patients with PSC not needing orthotopic liver transplantation (OLT) and those requiring OLT. Methods: A total of 41 patients with PSC and CD seen at the Cleveland Clinic between 1985 and 2011 were included in this study. Clinical and demographic variables were obtained regarding the outcome of CD in patients with and without OLT. Results: Patients with PSC-CD were divided into two groups: 20 without OLT (non-OLT) and 21 with OLT. 18 (85.7%) of patients in the OLT group had pancolitis in contrast to 14 (70%) in the non-OLT group. (p = 0.22). There were no significant differences regarding duration of CD, but the duration of PSC was longer in the OLT group [16.0 ± 7.8 vs. 10.3 ± 6.4, p = 0.01]. The OLT and non-OLT groups did not differ in the number of CD flares [0 (0, 0) vs. 0 (0, 5), p = 0.28) and need for surgery for CD [(6 (28.6%) vs. 9 (45%), p = 0.27]. Colon carcinoma and dysplasia were similar in the non-OLT and OLT groups [(4 (20%) vs. 3 (13.2%), p = 0.52]. On Cox regression analysis, OLT for PSC [Hazards ratio (HR) 1.2 (95% confidence interval (C.I.): 0.38-3.7, p = 0.79] did not impact the risk of colectomy. Conclusions: In contrast to UC, severe PSC requiring OLT does not appear to impact the clinical outcome of CD.
Background: We tested a panel of serological anti-glycan antibodies including the novel anti-lami... more Background: We tested a panel of serological anti-glycan antibodies including the novel anti-laminarin (Anti-L) and anti-chitin (Anti-C) antibodies in pediatric Crohn's disease (CD) patients for diagnosis of CD and association with complicated CD behavior. In addition, we compared this panel in pediatric CD with adult CD patients for possible changes in accuracy over time. Methods: Anti-L, Anti-C, anti-chitobioside (ACCA), anti-laminaribioside (ALCA), anti-mannobioside (AMCA), and anti-Saccaromyces cervisiae (gASCA) antibodies were tested in serum samples of 131 pediatric participants (59 CD, 27 ulcerative colitis [UC], and 45 noninflammatory bowel disease [IBD] controls) with enzyme-linked immunosorbent assay (ELISA). The results were compared to an adult cohort of 728 participants (355 CD, 129 UC, and 244 non-IBD controls). Results: In all, 78% of the pediatric CD patients were positive for at least one of the anti-glycan antibodies. gASCA was most accurate for the diagnosis of CD, but combined use of the antibodies improved differentiation of CD from UC. gASCA, AMCA, ALCA, or Anti-L and an increasing antibody level were independently linked to complicated CD behavior, CD-related surgery, and ileal disease location (odds ratio 3.9-8.7). Considering the age at sample procurement the accuracy of the markers compared to an adult cohort remained stable for the differentiation of CD versus UC as well as for the association with complications, CD-related surgery, and ileal disease involvement. Conclusions: A panel of anti-glycan antibodies including the novel Anti-L and Anti-C may aid in the differentiation of pediatric CD from UC and is associated with complicated CD behavior. The marker accuracy remained constant over time.
In patients with nonalcoholic fatty liver disease (NAFLD), a liver biopsy remains the only reliab... more In patients with nonalcoholic fatty liver disease (NAFLD), a liver biopsy remains the only reliable way to differentiate simple steatosis from nonalcoholic steatohepatitis (NASH). Noninvasive methods are urgently needed. Increasing evidence suggests hepatocyte apoptosis is a key mediator of liver injury in NAFLD. The aim of this study was to quantify hepatocyte apoptosis in plasma from patients with NAFLD and correlate it with histological severity. Plasma was obtained from 44 consecutive patients with suspected NAFLD at the time of liver biopsy. Histology was assessed blindly. Caspase-3-generated cytokeratin-18 fragments were measured in situ via immunohistochemistry and in vivo using a novel enzyme-linked immunosorbent assay. Plasma cytokeratin-18 fragments were markedly increased in patients with NASH compared with patients with simple steatosis or normal biopsies (median [interquartile range]: 765.
Background-The primary aim of this study was to compare the effects of pentoxifylline (PTX) versu... more Background-The primary aim of this study was to compare the effects of pentoxifylline (PTX) versus placebo on the histological features of NASH. Methods-55 adults with biopsy-confirmed NASH were randomized to receive PTX at a dose of 400mg three times a day (n=26) or placebo (n=29) over 1 year. The primary efficacy endpoint was defined as improvement on histological features of NASH through reduction in steatosis, lobular inflammation, and/or hepatocellular ballooning as reflected by a decrease of ≥ 2 points in the NAFLD activity score (NAS). Results-After 1 year, intention-to-treat analysis showed a decrease of >=2 points in the NAS in 38.5% of patients on PTX vs 13.8% of those on placebo (p=0.036). Per protocol analysis, a decrease of ≥ 2 points in the NAS from baseline was observed in 50% of the patients on PTX versus 15.4% of those on placebo (p=0.01). The mean change in NAS score from baseline was −1.6 in the PTX group, vs −0.1 in the placebo group (p<0.001). PTX significantly improved steatosis (mean change in score −0.9 vs −0.04 with placebo, p<0.001) and lobular inflammation (median change −1 vs 0 with placebo, p=0.02). No significant effects in hepatocellular ballooning were observed. PTX also improved liver fibrosis (mean change in fibrosis score was −0.2 among those on PTX versus +0.4 among those on placebo, p=0.038). Although not statistically significant (p=0.17), improvement in fibrosis was observed in a greater proportion (35%) of patients in the PTX group compared to placebo (15%). Adverse effects were similar in both groups. Conclusion-PTX improved histological features of NASH compared to placebo. PTX was well tolerated in patients with NASH (ClinicalTrials.gov number NCT00590161).
Background: In screening colonoscopies, an adenoma detection rate (ADR) of at least 25% and 15% a... more Background: In screening colonoscopies, an adenoma detection rate (ADR) of at least 25% and 15% are recommended benchmarks in men and women respectively. While ADR is a robust quality indicator for colonoscopy, it is not available to the endoscopist at the time of procedures. Calculation of ADR requires a subsequent cumbersome correlation of endoscopy and pathology reports. Limited data suggest that polypectomy rate (PR) correlates well with ADR and has been proposed as a useful quality indicator of colonoscopy. Aims: To determine whether PR correlates with ADR and to calculate benchmark PRs required for achieving the benchmark ADRs in men and women. Methods: A total of 7382 colonoscopy reports from 66 endoscopists including 41 gastroenterologists, 15 colorectal surgeons, 7 general surgeons and 3 other proceduralists during 2008-2009 were reviewed. Up to 120 procedures per endoscopist were randomly selected. Colonoscopy findings including quality of preparation, polyp size, location, morphology and pathology were retrieved. Patients with good or excellent bowel preparation were included while exclusions were incomplete colonoscopy, fair or poor bowel preparation, prior colon resection, FAP, HNPCC and IBD. ADR was defined as percentage of colonoscopies with at least one adenoma detected and similarly PR as percentage of colonoscopies in which at least one polyp was removed. Paired t-tests and linear regression analysis were used for statistical analysis. Data is presented as Mean Ϯ SD. Results: Colonoscopies of 3337 average risk patients met the inclusion criteria. Mean age of patients was 61 Ϯ 9.2 years and 49.5% were men.
Quality Indicators to Enhance Adenoma Detection Rate: Should There Be Reconsideration of the Curr... more Quality Indicators to Enhance Adenoma Detection Rate: Should There Be Reconsideration of the Current Standard? Madhusudhan R. Sanaka, Tushar Gohel, Amareshwar Podugu, Pokala R. Kiran, Prashanthi N. Thota, Rocio Lopez, James M. Church, James W. Collins, Carol A. Burke Gastroenterology, Cleveland Clinic, Cleveland, OH Background/Aims: The quality indicators (QI) for colonoscopy published in 2006 are based on studies done in the decade prior to their publication. Colonoscopic technology has improved, yet data shows incomplete protection from colonoscopy for cancer in the right colon. We believe a reassessment of detection rates for adenomas (ADR) and sessile serrated polyps (SSPDR) in average risk individuals is warranted. Knowledge of the ADR and SSPDR according to location in the colon, may improve the quality of colonoscopy. Our study aims were to determine Overall and segmental ADR and SSPDR in average risk individuals undergoing colonoscopy. Methods: Colonoscopy reports from a total of 66 endoscopists including 41 gastroenterologists, 15 colorectal surgeons, 7 general surgeons and 3 other proceduralists during 2008-2009 were reviewed. Up to 120 procedures per endoscopist were randomly selected. Colonoscopic findings including quality of preparation, polyp size, location, morphology and pathology were retrieved. Patients with good or excellent bowel preparation were included. Patients with incomplete colonoscopy, fair or poor bowel preparation, prior colon resection, FAP, HNPCC and IBD were excluded. ADR is defined as percentage of colonoscopies with at least one adenoma detected. SSPDR is defined similarly. Proximal colon consisted of cecum, ascending and transverse colon including splenic flexure while Distal colon included descending, sigmoid and rectum. Data is presented as mean sd or N (%). Detection rates were estimated for each endoscopist and comparisons between locations were made using paired t-tests. Results: 7382 colonoscopy reports were reviewed. 3337 average risk patients were included, 2560 (77%) had standard definition colonoscopy and 777 (23%) had high definition colonoscopy. The ADR was 24.9 10.5% (30.8 10.5% in Men and 19.1 12.8% in Women). ADR was greater in the Proximal than the Distal colon (15.5 7.9% vs 12.9 5.9%, p 0.011). This was similar for both genders, Men: Proximal 19 8.8%, Distal 16.7 8.5% and Women: Proximal 12.1 10.2%, Distal 9.0 7. SSPDR was 1.7 2.3 % (Proximal 1.2 1.8%, Distal 0.5 1.1%, p 0.003. This was again similar for Men: Proximal 1.2 2.4%, Distal 0.7 1.8% and Women: Proximal 1.1 2.2%, Distal 0.4 1.2%. Conclusions: The overall ADR in average risk individuals determined in a large group of endoscopists from various specialties at a tertiary care center is consistent with previously set ADR quality indicators. We demonstrate that both the ADR and SSPDR vary significantly by location within the colon, Proximal Distal. We propose two new quality indicators for colonoscopy in average risk individuals: SSPs should be detected in at least 1%; a minimum ADR and SSPDR should be set for the Proximal colon. 604 Does Inspection During Instrument Insertion Improve Adenoma Detection At Colonoscopy? A Randomized Controlled Trial David G. Hewett, Douglas K. Rex School of Medicine, The University of Queensland, Brisbane, QLD, Australia; Department of Medicine, Indiana University Medical Center, Indianapolis, IN Polyps are often missed during colonoscopy, even with meticulous technique. Polyps seen and not removed during instrument insertion are sometimes unable to be found during withdrawal. Aim: To investigate the impact of inspection during instrument insertion on adenoma detection in sedated patients undergoing routine screening or surveillance colonoscopy. Methods: We conducted a randomized controlled trial, in which 340 patients were randomized to undergo colonoscopy with inspection only performed during instrument withdrawal or colonoscopy with some of the inspection performed during instrument insertion. Eligibility criteria were: patients aged 50 years or older, ability to give informed consent and scheduled for elective colonoscopy. Exclusion criteria were previous surgical resection of the colon or rectum, inflammatory bowel disease, polyposis syndrome, and previously incomplete colonoscopy. Colonoscopy was performed using high definition colonoscopes with carbon dioxide insufflation, and a stopwatch was used to measure insertion and inspection times, with the aim of equal total inspection times between arms. The primary outcome measure was the adenoma detection rate in the two study groups. Group comparisons were performed using Wilcoxon rank sum or chisquare tests as appropriate. Results: Background demographic characteristics of the patients in the two study groups were equivalent (Table 1: mean age 63.0, range 47-85; male 44%). Colonoscopy-related variables were also similar, including indication, quality of bowel preparation, mean total procedure time, mean total…
contraceptives), and baseline SCCAI and FES. RESULTS: We identified 45 patients with the followin... more contraceptives), and baseline SCCAI and FES. RESULTS: We identified 45 patients with the following demographic information: mean age 56 years; 29 women; mean duration of UC 17 years; and mean time interval between surveillance colonoscopies 32 months. At baseline, 8 patients (18%) had clinically active disease and 10 (22%) had endoscopically active disease;.at follow-up, 9 (20%) had clinically active disease and 12 (27%) had endoscopically active disease. In multivariable analysis, only baseline FES > 1 was independently predictive of future clinically active disease with an odds ratio (OR) of 14.4 (95% confidence interval [CI], 2.48-83.4; p = 0.003). With respect to predicting future endoscopically active disease, only baseline SCCAI > 2 and FES > 1 were independently predictive with ORs of 56.2 (95% CI, 4.36-724; p = 0.002) and 47.5 (95% CI, 4.79-471; p = 0.001), respectively. CONCLUSIONS: There were no demographic variables or patterns of medication use that predicted the clinical and endoscopic course in patients with UC. The baseline endoscopic score was the only independent predictor of the future clinical disease activity, and both the baseline clinical and endoscopic scores were the only independent predictors of future endoscopic disease activity.
Introduction: Endoscopic ultrasound (EUS) has been considered as the most accurate modality avail... more Introduction: Endoscopic ultrasound (EUS) has been considered as the most accurate modality available to assess the T-stage of ampullary tumors, which is critical for planning endoscopic or surgical intenvention. Its accuracy in T-staging, however, is as low as 70% and has the tendency to overestimate the depth of tumor invasion. The majority of these data were derived from small sample size studies. Aim: To evaluate the accuracy of EUS in T-staging of ampullary tumor in patients who undergo endoscopic ampullectomy. Methods: From 2004 to 2007, data on 40 patients (21 male; 62.0 AE 2.7 yr) who underwent either diagnostic or therapeutic ampullectomy for ampullary tumors by a single endoscopist were reviewed. All patients had a pre-ampullectomy EUS for staging with stent(s) removed prior to EUS examination. All resected specimens were collected for histological examination. The accuracy of pre-ampullectomy EUS was compared to the histological findings. Results: All ampullary tumors (diameter: 25.6 AE 2.6 mm) were successfully resected endoscopically with snare technique, but 5 patients required Whipple's resection subsequently. Compared to histology, EUS was correctly T-staged 88% (35/40) patients with 97% sensitivity, 56% specificity, 88% PPV and 83% NPV. Only one patient with histological T1 were staged as T2 on EUS because intra-ductal tumor was visible in the distal pancreatic duct. This patient had no evidence of recurrence and still alive. In contrast, 44% (4/9) patients with histological T2 were ''under-staged'' as T1 on EUS as the invasion into the muscularis propria were not seen on EUS. Overall, only 33% (2/6) patients with tumor invasion into the muscularis propria were detected on EUS. Conclusion: Although the overall accuracy and sensitivity of EUS in T-staging of ampullary tumor were high, the specificity was poor and a significant proportion of patients was ''under-staged'' due to the lack of accuracy in the assessment of tumor invasion into the muscularis propria by EUS. All endoscopic ampullectomies, therefore, should be considered as ''diagnostic'' to provide ''en-bloc'' specimens for histological examination.
Anemia is frequently observed in patients with ileal pouch-anal anastomosis. The identification o... more Anemia is frequently observed in patients with ileal pouch-anal anastomosis. The identification of the underlying causes can be challenging. This study was designed to define the prevalence and to identify etiologic factors for anemia in this patient population. A prospectively maintained database and medical records of patients who had restorative proctocolectomy between 1998 and 2005 were reviewed. All patients with laboratory evaluation at least six months after the surgery were studied. The last reported hemoglobin served as the index value. All patients with anemia (hemoglobin &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 13.5 g/dl for males, &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;12 g/dl for females) were identified. A second group of randomly selected, ileal-pouch patients with normal hemoglobin served as control. Demographic and clinical variables were evaluated. A total of 389 patients (214 males) had documented hemoglobin values. Sixty-seven patients (17 percent; 40 males) had anemia. The prevalence of anemia was 19 and 15 percent in males and females, respectively. The prevalence was 17 percent among patients with underlying ulcerative colitis vs. 26 percent in patients with familial adenomatous polyposis (P = 0.27). The mean hemoglobin in the anemia group was 11.4 (median, 11.7) g/dl. One patient (2 percent) had severe (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;7 g/dl), 11 (16 percent) had moderate (7-9.9 g/dl), and 55 (82 percent) had mild (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or =10 g/dl) anemia. One patient (2 percent) had macrocytic, 16 (24 percent) had microcytic, and 49 (74 percent) had normocytic anemia. Sixteen patients (24 percent) had unidentified causes for anemia. Multivariable analysis showed that the presence of malignancy or desmoid tumor and the J-pouch configuration were the only independent risk factors associated with anemia. Anemia is common in ileal-pouch patients. Malignancy or desmoid tumor and J-pouch configuration are independent risk factors for anemia. One-fourth of the patients with anemia have unclear etiology.
Management of chronic refractory pouchitis, a common cause for pouch failure with pouch resection... more Management of chronic refractory pouchitis, a common cause for pouch failure with pouch resection or diversion, is often challenging. The aim of this study was to assess the efficacy and safety of a combination therapy of ciprofloxacin and tinidazole in patients with chronic refractory pouchitis compared with mesalamine therapy. Sixteen consecutive ulcerative colitis patients with chronic refractory pouchitis (disease&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;4 weeks and failure to respond to&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;4 weeks of single-antibiotic therapy) were treated with a four-week course of ciprofloxacin 1 g/day and tinidazole 15 mg/kg/day. A historic cohort of ten consecutive patients with chronic refractory pouchitis treated with oral (4 g/day), enema (8 g/day), or suppository (1 g/day) mesalamine served as controls. The Pouchitis Disease Activity Index, clinical remission, clinical response, the Cleveland Global Quality of Life, the Irritable Bowel Syndrome-Quality of Life, and the Short Inflammatory Bowel Disease Questionnaires scores were calculated before and after therapy and compared between the two treatment groups. Patients taking ciprofloxacin and tinidazole had a significant reduction in the total Pouchitis Disease Activity Index scores and subscores and a significant improvement in quality-of-life scores (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.002). For patients in the mesalamine group, there was a significant reduction in the total Pouchitis Disease Activity Index scores only. Patients in the antibiotic group had a greater reduction in the total Pouchitis Disease Activity Index scores and a greater improvement in the quality-of-life scores than those in the mesalamine group (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;or= 0.03). The rate of clinical remission and clinical response for the antibiotic group was 87.5 percent and 87.5 percent, respectively, and for the mesalamine group it was 50 percent and 50 percent, respectively (P = 0.069). Two patients in the antibiotic group (peripheral neuropathy and dysgeusia) developed adverse effects. Combination therapy with ciprofloxacin and tinidazole was generally well tolerated and was effective in treating patients with chronic refractory pouchitis.
Recurrence of Crohn&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;a... more Recurrence of Crohn&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease (CD) most commonly occurs in the neoterminal ileum near the stoma after fecal diverting ileostomy. Methods used to assess CD recurrence include small bowel series, ileostomy injection, computed tomography (CT) enterography, and capsule endoscopy. Retrograde ileoscopy via stoma is also a valuable tool for recognition of CD recurrence; however, this technique has not been formally studied. To evaluate the safety and utility of retrograde ileoscopy via stoma in patients with CD. Patients with CD who underwent ileoscopy via stoma between January 1, 2001, through December 31, 2008 were included. This was a retrospective study in a tertiary referral center. The main outcome measures were procedural complications and findings. A total of 243 ileoscopies were performed on 99 patients. The most common indications for ileoscopy were CD activity assessment in 34.5% and abdominal pain in 33.3%. The procedure was outpatient in 75.8%. Meperidine and midazolam were most commonly used. Average depth of intubation was 28.4 cm. CD recurrence was detected in 70% of patients. Biopsies were obtained during ileoscopy in 117 studies, and biopsy and ileoscopy findings correlated in 111 studies (94.8%). One polypectomy, 24 balloon stricture dilations, and 8 intralesional steroid injections were performed. All patients tolerated the procedure well without procedure- or anesthesia-related complications. No hospital admissions or procedure-related deaths occurred. Retrograde ileoscopy via stoma is a safe and effective procedure for evaluating recurrence of CD of the neoterminal ileum. It also allows for therapeutic interventions such as balloon dilatation of ileal strictures and steroid injections.
International journal of organ transplantation medicine, 2010
Recurrence of hepatitis C virus (HCV) infection following orthotopic liver transplantation (OLT) ... more Recurrence of hepatitis C virus (HCV) infection following orthotopic liver transplantation (OLT) is universal. There is paucity of data on the safety and efficacy of interleukin (IL)-2 receptor antagonist (IL-2RA) when added to the standard immunosuppression regimen in OLT recipients with recurrent HCV infection. To evaluate the efficacy of IL-2RA (Basiliximab) in preventing acute cellular rejection (ACR) in patients with recurrent HCV infection after OLT and to assess the impact of IL-2RA in promoting fibrosis progression in post-OLT recurrent HCV infection. Using an electronic pathology database, we identified all OLT/HCV patients with at least 2 post-OLT liver biopsies (1998-2006). Standard immunosuppression consisted of steroids and calcineurin inhibitor with and without mycophenolate mofetil. All patients who were transplanted after May 2004 received IL-2RA induction therapy. The Ludwig-Batts system was used to stage all biopsies (593 biopsies from 124 patients). The first biop...
Introduction: Anti-glycan antibodies are a promising tool for differential diagnosis and disease ... more Introduction: Anti-glycan antibodies are a promising tool for differential diagnosis and disease stratification of patients with Crohn's disease (CD). We longitudinally assessed level and status changes of anti-glycan antibodies over time in individual CD patients as well as determinants of this phenomenon. Methods: 859 serum samples derived from a cohort of 253 inflammatory bowel disease (IBD) patients (207 CD, 46 ulcerative colitis (UC)) were tested for the presence of anti-laminarin (Anti-L), anti-chitin (Anti-C), anti-chitobioside (ACCA), antilaminaribioside (ALCA), anti-mannobioside (AMCA) and anti-Saccharomyces cerevisiae (gASCA) antibodies by ELISA. All patients had at least two and up to eleven serum samples taken during the disease course. Results: Median follow-up time for CD was 17.4 months (Interquartile range (IQR) 8.0, 31.6 months) and for UC 10.9 months (IQR 4.9, 21.0 months). In a subgroup of CD subjects marked changes in the overall immune response (quartile sum score) and levels of individual markers were observed over time. The marker status (positive versus negative) remained widely stable. Neither clinical phenotype nor NOD2 genotype was associated with the observed fluctuations. In a longitudinal analysis neither changes in disease activity nor CD behavior led to alterations in the levels of the glycan markers. The ability of the panel to discriminate CD from UC or its association with CD phenotypes remained stable during follow-up. In the serum of UC patients neither significant level nor status changes were observed. Conclusions: While the levels of anti-glycan antibodies fluctuate in a subgroup of CD patients the antibody status is widely stable over time.
BackgroundNonalcoholic steatohepatitis (NASH), the most severe form of nonalcoholic fatty liver d... more BackgroundNonalcoholic steatohepatitis (NASH), the most severe form of nonalcoholic fatty liver disease (NAFLD), is associated with inflammation and increased oxidative stress. The neutrophil/lymphocyte ratio (N/L) integrates information on the inflammatory milieu and physiological stress.AimsThe aim of this study was to determine the utility of N/L ratio to predict the presence of NASH in patients with NAFLD.MethodsOur cohort consisted of 101 consecutive patients undergoing liver biopsy for clinical suspicion of NAFLD. Patients were divided into two groups: NASH group (n = 50) and not NASH group (n = 51). The stage of fibrosis was measured using a 4‐point scale. The total white cell count, neutrophil and lymphocyte counts were recorded, and the N/L ratio was calculated.ResultsThe mean age was 49.5 (±10.8) years and the mean BMI was 31.4 (±4.9) kg/m2. Patients with NASH had a higher N/L ratio compared with patients with not NASH [2.5 (1.9–3.3) and 1.6 (1.2–2.0), respectively, P <...
Nonalcoholic fatty liver disease (NAFLD) encompasses a spectrum of disease from simple steatosis ... more Nonalcoholic fatty liver disease (NAFLD) encompasses a spectrum of disease from simple steatosis to steatohepatitis, to fibrosis and cirrhosis. The paediatric NAFLD fibrosis index (PNFI) and transient elastography (TE) are potential noninvasive markers for fibrosis. To prospectively evaluate the performance of PNFI and TE in assessing clinically significant fibrosis in children with biopsy-proven NAFLD. Our cohort consisted of 67 consecutive children with biopsy-proven NAFLD. The stage of fibrosis was scored according to the Nonalcoholic Steatohepatitis Clinical Research Network. Fibrosis ≥ 2 was considered clinically significant. PNFI was calculated using age, waist circumference and triglycerides. TE was performed using the Fibroscan apparatus. Ten patients had fibrosis stage 2-3 and 57 patients had stage 0-1. Both PNFI and TE values were significantly higher in patients with significant fibrosis (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). The area under the receiver operating characteristic (ROC) curve for predicting significant fibrosis of PNFI and TE were 0.747 and 1.00 respectively (P = 0.005). The combined use of PNFI and TE could predict the presence or absence of clinically significant fibrosis in 98% of children with NAFLD. In children with NAFLD, the combination of PNFI and TE can be used to accurately assess the presence of clinically significant liver fibrosis. This will help to identify patients who should undergo liver biopsy because the confirmation of advanced fibrosis would lead to closer follow-up and screening for cirrhosis-related complications.
Background: Literature on endoscopic dilation of Crohn's disease (CD) strictures, especially for ... more Background: Literature on endoscopic dilation of Crohn's disease (CD) strictures, especially for primary (non-anastomotic) strictures is limited. Methods: A historical cohort study was performed on patients who underwent endoscopic stricture dilations for CD in our IBD center. Primary endpoint was the efficacy of first endoscopic dilation in preventing the need for surgery in primary strictures compared to anastomotic strictures. Cox proportional hazards models using robust sandwich covariance matrix estimate were used to evaluate the need for surgery and any further endoscopic intervention. Results: In our study cohort (mean age 42.2 ± 13.1 years, 57% females, 16.4% current smokers, and median follow-up 1.8 years), 128 patients underwent a total of 430 endoscopic stricture dilations for 169 strictures (88 primary, 81 secondary). Forty-two patients (32.8%) required surgery in the follow-up period, with a mean interval period between first dilation and surgery of 33 months. There was no difference between primary or anastomotic strictures with respect to
Background and aim: Crohn's disease (CD) is associated with primary sclerosing cholangitis (PSC).... more Background and aim: Crohn's disease (CD) is associated with primary sclerosing cholangitis (PSC). The aim of the study was to study the association between the severity of PSC and clinical outcome of CD, comparing the course of CD in patients with PSC not needing orthotopic liver transplantation (OLT) and those requiring OLT. Methods: A total of 41 patients with PSC and CD seen at the Cleveland Clinic between 1985 and 2011 were included in this study. Clinical and demographic variables were obtained regarding the outcome of CD in patients with and without OLT. Results: Patients with PSC-CD were divided into two groups: 20 without OLT (non-OLT) and 21 with OLT. 18 (85.7%) of patients in the OLT group had pancolitis in contrast to 14 (70%) in the non-OLT group. (p = 0.22). There were no significant differences regarding duration of CD, but the duration of PSC was longer in the OLT group [16.0 ± 7.8 vs. 10.3 ± 6.4, p = 0.01]. The OLT and non-OLT groups did not differ in the number of CD flares [0 (0, 0) vs. 0 (0, 5), p = 0.28) and need for surgery for CD [(6 (28.6%) vs. 9 (45%), p = 0.27]. Colon carcinoma and dysplasia were similar in the non-OLT and OLT groups [(4 (20%) vs. 3 (13.2%), p = 0.52]. On Cox regression analysis, OLT for PSC [Hazards ratio (HR) 1.2 (95% confidence interval (C.I.): 0.38-3.7, p = 0.79] did not impact the risk of colectomy. Conclusions: In contrast to UC, severe PSC requiring OLT does not appear to impact the clinical outcome of CD.
Background: We tested a panel of serological anti-glycan antibodies including the novel anti-lami... more Background: We tested a panel of serological anti-glycan antibodies including the novel anti-laminarin (Anti-L) and anti-chitin (Anti-C) antibodies in pediatric Crohn's disease (CD) patients for diagnosis of CD and association with complicated CD behavior. In addition, we compared this panel in pediatric CD with adult CD patients for possible changes in accuracy over time. Methods: Anti-L, Anti-C, anti-chitobioside (ACCA), anti-laminaribioside (ALCA), anti-mannobioside (AMCA), and anti-Saccaromyces cervisiae (gASCA) antibodies were tested in serum samples of 131 pediatric participants (59 CD, 27 ulcerative colitis [UC], and 45 noninflammatory bowel disease [IBD] controls) with enzyme-linked immunosorbent assay (ELISA). The results were compared to an adult cohort of 728 participants (355 CD, 129 UC, and 244 non-IBD controls). Results: In all, 78% of the pediatric CD patients were positive for at least one of the anti-glycan antibodies. gASCA was most accurate for the diagnosis of CD, but combined use of the antibodies improved differentiation of CD from UC. gASCA, AMCA, ALCA, or Anti-L and an increasing antibody level were independently linked to complicated CD behavior, CD-related surgery, and ileal disease location (odds ratio 3.9-8.7). Considering the age at sample procurement the accuracy of the markers compared to an adult cohort remained stable for the differentiation of CD versus UC as well as for the association with complications, CD-related surgery, and ileal disease involvement. Conclusions: A panel of anti-glycan antibodies including the novel Anti-L and Anti-C may aid in the differentiation of pediatric CD from UC and is associated with complicated CD behavior. The marker accuracy remained constant over time.
In patients with nonalcoholic fatty liver disease (NAFLD), a liver biopsy remains the only reliab... more In patients with nonalcoholic fatty liver disease (NAFLD), a liver biopsy remains the only reliable way to differentiate simple steatosis from nonalcoholic steatohepatitis (NASH). Noninvasive methods are urgently needed. Increasing evidence suggests hepatocyte apoptosis is a key mediator of liver injury in NAFLD. The aim of this study was to quantify hepatocyte apoptosis in plasma from patients with NAFLD and correlate it with histological severity. Plasma was obtained from 44 consecutive patients with suspected NAFLD at the time of liver biopsy. Histology was assessed blindly. Caspase-3-generated cytokeratin-18 fragments were measured in situ via immunohistochemistry and in vivo using a novel enzyme-linked immunosorbent assay. Plasma cytokeratin-18 fragments were markedly increased in patients with NASH compared with patients with simple steatosis or normal biopsies (median [interquartile range]: 765.
Background-The primary aim of this study was to compare the effects of pentoxifylline (PTX) versu... more Background-The primary aim of this study was to compare the effects of pentoxifylline (PTX) versus placebo on the histological features of NASH. Methods-55 adults with biopsy-confirmed NASH were randomized to receive PTX at a dose of 400mg three times a day (n=26) or placebo (n=29) over 1 year. The primary efficacy endpoint was defined as improvement on histological features of NASH through reduction in steatosis, lobular inflammation, and/or hepatocellular ballooning as reflected by a decrease of ≥ 2 points in the NAFLD activity score (NAS). Results-After 1 year, intention-to-treat analysis showed a decrease of >=2 points in the NAS in 38.5% of patients on PTX vs 13.8% of those on placebo (p=0.036). Per protocol analysis, a decrease of ≥ 2 points in the NAS from baseline was observed in 50% of the patients on PTX versus 15.4% of those on placebo (p=0.01). The mean change in NAS score from baseline was −1.6 in the PTX group, vs −0.1 in the placebo group (p<0.001). PTX significantly improved steatosis (mean change in score −0.9 vs −0.04 with placebo, p<0.001) and lobular inflammation (median change −1 vs 0 with placebo, p=0.02). No significant effects in hepatocellular ballooning were observed. PTX also improved liver fibrosis (mean change in fibrosis score was −0.2 among those on PTX versus +0.4 among those on placebo, p=0.038). Although not statistically significant (p=0.17), improvement in fibrosis was observed in a greater proportion (35%) of patients in the PTX group compared to placebo (15%). Adverse effects were similar in both groups. Conclusion-PTX improved histological features of NASH compared to placebo. PTX was well tolerated in patients with NASH (ClinicalTrials.gov number NCT00590161).
Background: In screening colonoscopies, an adenoma detection rate (ADR) of at least 25% and 15% a... more Background: In screening colonoscopies, an adenoma detection rate (ADR) of at least 25% and 15% are recommended benchmarks in men and women respectively. While ADR is a robust quality indicator for colonoscopy, it is not available to the endoscopist at the time of procedures. Calculation of ADR requires a subsequent cumbersome correlation of endoscopy and pathology reports. Limited data suggest that polypectomy rate (PR) correlates well with ADR and has been proposed as a useful quality indicator of colonoscopy. Aims: To determine whether PR correlates with ADR and to calculate benchmark PRs required for achieving the benchmark ADRs in men and women. Methods: A total of 7382 colonoscopy reports from 66 endoscopists including 41 gastroenterologists, 15 colorectal surgeons, 7 general surgeons and 3 other proceduralists during 2008-2009 were reviewed. Up to 120 procedures per endoscopist were randomly selected. Colonoscopy findings including quality of preparation, polyp size, location, morphology and pathology were retrieved. Patients with good or excellent bowel preparation were included while exclusions were incomplete colonoscopy, fair or poor bowel preparation, prior colon resection, FAP, HNPCC and IBD. ADR was defined as percentage of colonoscopies with at least one adenoma detected and similarly PR as percentage of colonoscopies in which at least one polyp was removed. Paired t-tests and linear regression analysis were used for statistical analysis. Data is presented as Mean Ϯ SD. Results: Colonoscopies of 3337 average risk patients met the inclusion criteria. Mean age of patients was 61 Ϯ 9.2 years and 49.5% were men.
Quality Indicators to Enhance Adenoma Detection Rate: Should There Be Reconsideration of the Curr... more Quality Indicators to Enhance Adenoma Detection Rate: Should There Be Reconsideration of the Current Standard? Madhusudhan R. Sanaka, Tushar Gohel, Amareshwar Podugu, Pokala R. Kiran, Prashanthi N. Thota, Rocio Lopez, James M. Church, James W. Collins, Carol A. Burke Gastroenterology, Cleveland Clinic, Cleveland, OH Background/Aims: The quality indicators (QI) for colonoscopy published in 2006 are based on studies done in the decade prior to their publication. Colonoscopic technology has improved, yet data shows incomplete protection from colonoscopy for cancer in the right colon. We believe a reassessment of detection rates for adenomas (ADR) and sessile serrated polyps (SSPDR) in average risk individuals is warranted. Knowledge of the ADR and SSPDR according to location in the colon, may improve the quality of colonoscopy. Our study aims were to determine Overall and segmental ADR and SSPDR in average risk individuals undergoing colonoscopy. Methods: Colonoscopy reports from a total of 66 endoscopists including 41 gastroenterologists, 15 colorectal surgeons, 7 general surgeons and 3 other proceduralists during 2008-2009 were reviewed. Up to 120 procedures per endoscopist were randomly selected. Colonoscopic findings including quality of preparation, polyp size, location, morphology and pathology were retrieved. Patients with good or excellent bowel preparation were included. Patients with incomplete colonoscopy, fair or poor bowel preparation, prior colon resection, FAP, HNPCC and IBD were excluded. ADR is defined as percentage of colonoscopies with at least one adenoma detected. SSPDR is defined similarly. Proximal colon consisted of cecum, ascending and transverse colon including splenic flexure while Distal colon included descending, sigmoid and rectum. Data is presented as mean sd or N (%). Detection rates were estimated for each endoscopist and comparisons between locations were made using paired t-tests. Results: 7382 colonoscopy reports were reviewed. 3337 average risk patients were included, 2560 (77%) had standard definition colonoscopy and 777 (23%) had high definition colonoscopy. The ADR was 24.9 10.5% (30.8 10.5% in Men and 19.1 12.8% in Women). ADR was greater in the Proximal than the Distal colon (15.5 7.9% vs 12.9 5.9%, p 0.011). This was similar for both genders, Men: Proximal 19 8.8%, Distal 16.7 8.5% and Women: Proximal 12.1 10.2%, Distal 9.0 7. SSPDR was 1.7 2.3 % (Proximal 1.2 1.8%, Distal 0.5 1.1%, p 0.003. This was again similar for Men: Proximal 1.2 2.4%, Distal 0.7 1.8% and Women: Proximal 1.1 2.2%, Distal 0.4 1.2%. Conclusions: The overall ADR in average risk individuals determined in a large group of endoscopists from various specialties at a tertiary care center is consistent with previously set ADR quality indicators. We demonstrate that both the ADR and SSPDR vary significantly by location within the colon, Proximal Distal. We propose two new quality indicators for colonoscopy in average risk individuals: SSPs should be detected in at least 1%; a minimum ADR and SSPDR should be set for the Proximal colon. 604 Does Inspection During Instrument Insertion Improve Adenoma Detection At Colonoscopy? A Randomized Controlled Trial David G. Hewett, Douglas K. Rex School of Medicine, The University of Queensland, Brisbane, QLD, Australia; Department of Medicine, Indiana University Medical Center, Indianapolis, IN Polyps are often missed during colonoscopy, even with meticulous technique. Polyps seen and not removed during instrument insertion are sometimes unable to be found during withdrawal. Aim: To investigate the impact of inspection during instrument insertion on adenoma detection in sedated patients undergoing routine screening or surveillance colonoscopy. Methods: We conducted a randomized controlled trial, in which 340 patients were randomized to undergo colonoscopy with inspection only performed during instrument withdrawal or colonoscopy with some of the inspection performed during instrument insertion. Eligibility criteria were: patients aged 50 years or older, ability to give informed consent and scheduled for elective colonoscopy. Exclusion criteria were previous surgical resection of the colon or rectum, inflammatory bowel disease, polyposis syndrome, and previously incomplete colonoscopy. Colonoscopy was performed using high definition colonoscopes with carbon dioxide insufflation, and a stopwatch was used to measure insertion and inspection times, with the aim of equal total inspection times between arms. The primary outcome measure was the adenoma detection rate in the two study groups. Group comparisons were performed using Wilcoxon rank sum or chisquare tests as appropriate. Results: Background demographic characteristics of the patients in the two study groups were equivalent (Table 1: mean age 63.0, range 47-85; male 44%). Colonoscopy-related variables were also similar, including indication, quality of bowel preparation, mean total procedure time, mean total…
contraceptives), and baseline SCCAI and FES. RESULTS: We identified 45 patients with the followin... more contraceptives), and baseline SCCAI and FES. RESULTS: We identified 45 patients with the following demographic information: mean age 56 years; 29 women; mean duration of UC 17 years; and mean time interval between surveillance colonoscopies 32 months. At baseline, 8 patients (18%) had clinically active disease and 10 (22%) had endoscopically active disease;.at follow-up, 9 (20%) had clinically active disease and 12 (27%) had endoscopically active disease. In multivariable analysis, only baseline FES > 1 was independently predictive of future clinically active disease with an odds ratio (OR) of 14.4 (95% confidence interval [CI], 2.48-83.4; p = 0.003). With respect to predicting future endoscopically active disease, only baseline SCCAI > 2 and FES > 1 were independently predictive with ORs of 56.2 (95% CI, 4.36-724; p = 0.002) and 47.5 (95% CI, 4.79-471; p = 0.001), respectively. CONCLUSIONS: There were no demographic variables or patterns of medication use that predicted the clinical and endoscopic course in patients with UC. The baseline endoscopic score was the only independent predictor of the future clinical disease activity, and both the baseline clinical and endoscopic scores were the only independent predictors of future endoscopic disease activity.
Introduction: Endoscopic ultrasound (EUS) has been considered as the most accurate modality avail... more Introduction: Endoscopic ultrasound (EUS) has been considered as the most accurate modality available to assess the T-stage of ampullary tumors, which is critical for planning endoscopic or surgical intenvention. Its accuracy in T-staging, however, is as low as 70% and has the tendency to overestimate the depth of tumor invasion. The majority of these data were derived from small sample size studies. Aim: To evaluate the accuracy of EUS in T-staging of ampullary tumor in patients who undergo endoscopic ampullectomy. Methods: From 2004 to 2007, data on 40 patients (21 male; 62.0 AE 2.7 yr) who underwent either diagnostic or therapeutic ampullectomy for ampullary tumors by a single endoscopist were reviewed. All patients had a pre-ampullectomy EUS for staging with stent(s) removed prior to EUS examination. All resected specimens were collected for histological examination. The accuracy of pre-ampullectomy EUS was compared to the histological findings. Results: All ampullary tumors (diameter: 25.6 AE 2.6 mm) were successfully resected endoscopically with snare technique, but 5 patients required Whipple's resection subsequently. Compared to histology, EUS was correctly T-staged 88% (35/40) patients with 97% sensitivity, 56% specificity, 88% PPV and 83% NPV. Only one patient with histological T1 were staged as T2 on EUS because intra-ductal tumor was visible in the distal pancreatic duct. This patient had no evidence of recurrence and still alive. In contrast, 44% (4/9) patients with histological T2 were ''under-staged'' as T1 on EUS as the invasion into the muscularis propria were not seen on EUS. Overall, only 33% (2/6) patients with tumor invasion into the muscularis propria were detected on EUS. Conclusion: Although the overall accuracy and sensitivity of EUS in T-staging of ampullary tumor were high, the specificity was poor and a significant proportion of patients was ''under-staged'' due to the lack of accuracy in the assessment of tumor invasion into the muscularis propria by EUS. All endoscopic ampullectomies, therefore, should be considered as ''diagnostic'' to provide ''en-bloc'' specimens for histological examination.
Anemia is frequently observed in patients with ileal pouch-anal anastomosis. The identification o... more Anemia is frequently observed in patients with ileal pouch-anal anastomosis. The identification of the underlying causes can be challenging. This study was designed to define the prevalence and to identify etiologic factors for anemia in this patient population. A prospectively maintained database and medical records of patients who had restorative proctocolectomy between 1998 and 2005 were reviewed. All patients with laboratory evaluation at least six months after the surgery were studied. The last reported hemoglobin served as the index value. All patients with anemia (hemoglobin &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 13.5 g/dl for males, &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;12 g/dl for females) were identified. A second group of randomly selected, ileal-pouch patients with normal hemoglobin served as control. Demographic and clinical variables were evaluated. A total of 389 patients (214 males) had documented hemoglobin values. Sixty-seven patients (17 percent; 40 males) had anemia. The prevalence of anemia was 19 and 15 percent in males and females, respectively. The prevalence was 17 percent among patients with underlying ulcerative colitis vs. 26 percent in patients with familial adenomatous polyposis (P = 0.27). The mean hemoglobin in the anemia group was 11.4 (median, 11.7) g/dl. One patient (2 percent) had severe (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;7 g/dl), 11 (16 percent) had moderate (7-9.9 g/dl), and 55 (82 percent) had mild (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or =10 g/dl) anemia. One patient (2 percent) had macrocytic, 16 (24 percent) had microcytic, and 49 (74 percent) had normocytic anemia. Sixteen patients (24 percent) had unidentified causes for anemia. Multivariable analysis showed that the presence of malignancy or desmoid tumor and the J-pouch configuration were the only independent risk factors associated with anemia. Anemia is common in ileal-pouch patients. Malignancy or desmoid tumor and J-pouch configuration are independent risk factors for anemia. One-fourth of the patients with anemia have unclear etiology.
Management of chronic refractory pouchitis, a common cause for pouch failure with pouch resection... more Management of chronic refractory pouchitis, a common cause for pouch failure with pouch resection or diversion, is often challenging. The aim of this study was to assess the efficacy and safety of a combination therapy of ciprofloxacin and tinidazole in patients with chronic refractory pouchitis compared with mesalamine therapy. Sixteen consecutive ulcerative colitis patients with chronic refractory pouchitis (disease&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;4 weeks and failure to respond to&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;4 weeks of single-antibiotic therapy) were treated with a four-week course of ciprofloxacin 1 g/day and tinidazole 15 mg/kg/day. A historic cohort of ten consecutive patients with chronic refractory pouchitis treated with oral (4 g/day), enema (8 g/day), or suppository (1 g/day) mesalamine served as controls. The Pouchitis Disease Activity Index, clinical remission, clinical response, the Cleveland Global Quality of Life, the Irritable Bowel Syndrome-Quality of Life, and the Short Inflammatory Bowel Disease Questionnaires scores were calculated before and after therapy and compared between the two treatment groups. Patients taking ciprofloxacin and tinidazole had a significant reduction in the total Pouchitis Disease Activity Index scores and subscores and a significant improvement in quality-of-life scores (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.002). For patients in the mesalamine group, there was a significant reduction in the total Pouchitis Disease Activity Index scores only. Patients in the antibiotic group had a greater reduction in the total Pouchitis Disease Activity Index scores and a greater improvement in the quality-of-life scores than those in the mesalamine group (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;or= 0.03). The rate of clinical remission and clinical response for the antibiotic group was 87.5 percent and 87.5 percent, respectively, and for the mesalamine group it was 50 percent and 50 percent, respectively (P = 0.069). Two patients in the antibiotic group (peripheral neuropathy and dysgeusia) developed adverse effects. Combination therapy with ciprofloxacin and tinidazole was generally well tolerated and was effective in treating patients with chronic refractory pouchitis.
Recurrence of Crohn&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;a... more Recurrence of Crohn&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease (CD) most commonly occurs in the neoterminal ileum near the stoma after fecal diverting ileostomy. Methods used to assess CD recurrence include small bowel series, ileostomy injection, computed tomography (CT) enterography, and capsule endoscopy. Retrograde ileoscopy via stoma is also a valuable tool for recognition of CD recurrence; however, this technique has not been formally studied. To evaluate the safety and utility of retrograde ileoscopy via stoma in patients with CD. Patients with CD who underwent ileoscopy via stoma between January 1, 2001, through December 31, 2008 were included. This was a retrospective study in a tertiary referral center. The main outcome measures were procedural complications and findings. A total of 243 ileoscopies were performed on 99 patients. The most common indications for ileoscopy were CD activity assessment in 34.5% and abdominal pain in 33.3%. The procedure was outpatient in 75.8%. Meperidine and midazolam were most commonly used. Average depth of intubation was 28.4 cm. CD recurrence was detected in 70% of patients. Biopsies were obtained during ileoscopy in 117 studies, and biopsy and ileoscopy findings correlated in 111 studies (94.8%). One polypectomy, 24 balloon stricture dilations, and 8 intralesional steroid injections were performed. All patients tolerated the procedure well without procedure- or anesthesia-related complications. No hospital admissions or procedure-related deaths occurred. Retrograde ileoscopy via stoma is a safe and effective procedure for evaluating recurrence of CD of the neoterminal ileum. It also allows for therapeutic interventions such as balloon dilatation of ileal strictures and steroid injections.
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Papers by Rocio Lopez