Is fasting beneficial for hospitalized patients with inflammatory bowel diseases?

BACKGROUND/AIMS: Patients with inflammatory bowel disease (IBD) are usually hospitalized because of aggravated gastrointestinal symptoms. Many clinicians empirically advise these patients to fast once they are admitted. However, there has been no evidence that maintaining a complete bowel rest improves the disease course. Therefore, we aimed to investigate the effects of fasting on disease course in admitted patients with IBD or intestinal Behçet's disease. METHODS: A total of 222 patients with IBD or intestinal Behçet's disease, who were admitted for disease-related symptoms, were retrospectively analyzed. We divided them into 2 groups: fasting group (allowed to take sips of water but no food at the time of admission) and dietary group (received liquid, soft, or general diet). RESULTS: On admission, 124 patients (55.9%) started fasting and 98 patients (44.1%) started diet immediately. Among patients hospitalized through the emergency room, a significantly higher proportion underwent fasting (63.7% vs. 21.4%, P<0.001); however, 96.0% of the patients experienced dietary changes. Corticosteroid use (P<0.001; hazard ratio, 2.445; 95% confidence interval, 1.506-3.969) was significantly associated with a reduction in the disease activity score, although there was no significant difference between the fasting group and the dietary group in disease activity reduction (P=0.111) on multivariate analysis. CONCLUSIONS: In terms of disease activity reduction, there was no significant difference between the fasting and dietary groups in admitted patients with IBD, suggesting that imprudent fasting is not helpful in improving the disease course. Therefore, peroral diet should not be avoided unless not tolerated by the patient.ope

Updated treatment strategies for intestinal Behcet's disease

Behcet's disease (BD) is a chronic, idiopathic, relapsing immune-mediated disease involving multiple organs, and is characterized by recurrent oral and genital ulcers, ocular disease, gastrointestinal ulcers, vascular diseases, and skin lesions. In particular, gastrointestinal involvement in BD is followed by severe complications, including massive bleeding, bowel perforation, and fistula, which can lead to significant morbidity and mortality. However, the management of intestinal BD has not yet been properly established. Intestinal BD patients with a severe clinical course experience frequent disease aggravations and often require recurrent corticosteroid and/or immunomodulatory therapies, or even surgery. However, a considerable number of patients with intestinal BD are often refractory to conventional therapies such as corticosteroids and immunomodulators. Recently, there has been a line of evidence suggesting that biologics such as infliximab and adalimumab are effective in treating intestinal BD. Moreover, new biologics targeting proteins other than tumor necrosis factor alpha are emerging and are under active investigation. Therefore, in this paper, we review the current therapeutic strategies and new clinical data for the treatment of intestinal BD.ope

Microbial changes in stool, saliva, serum, and urine before and after anti-TNF-α therapy in patients with inflammatory bowel diseases

Inflammatory bowel diseases (IBD), including Crohn's disease and ulcerative colitis, are chronic immune-mediated intestinal inflammatory disorders associated with microbial dysbiosis at multiple sites, particularly the gut. Anti-tumor necrosis factor-α (TNF-α) agents are important treatments for IBD. We investigated whether microbiome changes at multiple sites can predict the effectiveness of such treatment in IBD. Stool, saliva, serum, and urine biosamples were collected from 19 IBD patients before (V1) and 3 months after (V2) anti-TNF-α treatment, and 19 healthy subjects (control). Microbiota analysis was performed using extracellular vesicles (EVs; all four sample types) and next-generation sequencing (NGS; stool and saliva). The stool, using NGS analysis, was the only sample type in which α-diversity differed significantly between the IBD and control groups at V1 and V2. Relative to non-responders, responders to anti-TNF-α treatment had significantly higher levels of Firmicutes (phylum), Clostridia (class), and Ruminococcaceae (family) in V1 stool, and Prevotella in V1 saliva. Non-responders had significantly higher V2 serum and urine levels of Lachnospiraceae than responders. Finally, Acidovorax caeni was detected in all V1 sample types in responders, but was not detected in non-responders. Microbiome changes at multiple sites may predict the effectiveness of anti-TNF-α treatment in IBD, warranting further research.ope

Incidence and risk factors of micronutrient deficiency in patients with IBD and intestinal Behçet's disease: folate, vitamin B12, 25-OH-vitamin D, and ferritin

Background: Patients with inflammatory bowel disease (IBD) and intestinal Behçet's disease (BD) are vulnerable to micronutrient deficiencies due to diarrhea-related gastrointestinal loss and poor dietary intake caused by disease-related anorexia. However, few studies have investigated the incidence and risk factors for micronutrient deficiency. Methods: We retrospectively analyzed 205 patients with IBD who underwent micronutrient examination, including folate, vitamin B12, 25-OH-vitamin D, and/or ferritin level quantification, with follow-up blood tests conducted 6 months later. Results: Eighty patients (39.0%), who were deficient in any of the four micronutrients, were classified as the deficiency group, and the remaining 125 (61.0%) were classified as the non-deficient group. Compared to those in the non-deficiency group, patients in the deficiency group were much younger, had more Crohn's disease (CD) patients, more patients with a history of bowel operation, and significantly less 5-amino salicylic acid usage. Multivariate analysis revealed that CD and bowel operation were significant independent factors associated with micronutrient deficiency. Conclusions: The incidence of micronutrient deficiency was high (39.0%). Factors including CD, bowel operation, and younger ages were found to be associated with higher risks of deficiency. Therefore, patients with IBD, especially young patients with CD who have undergone bowel resection surgery, need more attention paid to micronutrition.ope

Impact and outcomes of nutritional support team intervention in patients with gastrointestinal disease in the intensive care unit

Nutritional support has become an important intervention for critically ill patients. Many studies have reported on the effects of nutritional support for the patients within the intensive care unit (ICU); however, no studies have specifically assessed patients with gastrointestinal diseases who may have difficulty absorbing enteral nutrition (EN) in the ICU.Sixty-two patients with gastrointestinal disease were admitted to the ICU between August 2014 and August 2016 at a single tertiary university hospital. We analyzed 2 different patient groups in a retrospective cohort study: those who received nutritional support team (NST) intervention and those who did not.Forty-four (71.0%) patients received nutritional support in ICU and 18 (29.0%) did not. Variables including male sex, high albumin or prealbumin level at the time of ICU admission, and short transition period into EN showed statistically significant association with lower mortality on the univariate analysis (all P < .05). Multivariate analysis revealed that longer length of hospital stay (P = .013; hazard ratio [HR], 0.972; 95% confidence interval [CI], 0.951-0.994), shorter transition into EN (P = .014; HR, 1.040; 95% CI, 1.008-1.072), higher prealbumin level (P = .049; HR, 0.988; 95% CI, 0.976-1.000), and NST intervention (P = .022; HR, 0.356; 95% CI, 0.147-0.862) were independent prognostic factors for lower mortality.In conclusion, NST intervention related to early initiated EN, and high prealbumin levels are beneficial to decrease mortality in the acutely ill patients with GI disease.ope

Spontaneous rupture of hepatic metastasis from a thymoma: A case report

Bleeding resulting from spontaneous rupture of the liver is an infrequent but potentially life threatening complication that may be associated with an underlying liver disease. A hepatocellular carcinoma or hepatic adenoma is frequently reported is such cases. However, hemoperitoneum resulting from a hepatic metastatic thymoma is extremely rare. Here, we present a case of a 62-year-old man with hypovolemic shock induced by ruptured hepatic metastasis from a thymoma. At the first hospital admission, the patient had a 45-mm anterior mediastinal mass that was eventually diagnosed as a type A thymoma. The mass was excised, and the patient was disease-free for 6 years. He experienced sudden-onset right upper quadrant pain and was again admitted to our hospital. We noted large hemoperitoneum with a 10-cm encapsulated mass in S5/8 and a 2.3-cm nodular lesion in the right upper quadrant of the abdomen. He was diagnosed with hepatic metastasis from the thymoma, and he underwent chemotherapy and surgical excision.ope

Magnetic resonance enterography predicts the prognosis of Crohn’s disease

Background/Aims: Magnetic resonance enterography (MRE) has emerged as an important tool in the diagnosis and follow-up of Crohn's disease (CD). The aim of this study was to evaluate whether MRE findings could predict the prognosis of CD. Methods: In this retrospective study, a total of 173 patients with clinical remission of CD (n=61) or active CD (n=112) were identified. The outcomes of clinical relapse, admission, surgery, and need for other medications according to the MRE findings were evaluated. Results: The presence of active inflammation on MRE was observed in 93 (83%) patients with clinically active CD and in 44 (72.1%) patients with clinical remission of CD, without a statistically significant difference (P=0.091). In multivariate analysis, active inflammation on MRE increased the risk for clinical relapse (hazard ratio [HR], 6.985; 95% confidence interval [CI], 1.024-47.649) in patients with clinical remission of CD. In patients with clinically active CD, active inflammation on MRE increased the risk for CD-related hospitalization (HR, 2.970; 95% CI, 1.006-8.772). Conclusions: The presence of active inflammation on MRE was significantly associated with poor prognosis both in patients with clinical remission of CD and in those with active CD.ope

염증성 장질환 환자에서 항 TNF-α 치료 전후의 대변, 타액, 혈청 및 소변의 미생물 변화

크론병 및 궤양성 대장염을 포함한 염증성 장질환은 여러 신체 부위, 특히 장에서 미생물 불균형 (dysbiosis)와 관련된 만성 면역 매개 장 염증 질환입니다. 항 종양 괴사 인자-알파 (항-TNF-α) 제제는 염증성 장질환 환자의 치료에서 중요한 치료제로, 이 연구는 여러 부위의 미생물 군집의 변화가 염증성 장질환 환자에서 항 TNF-α 치료의 효과를 예측할 수 있는지를 조사하고자 하였습니다. 대변, 타액, 혈청 및 소변의 검체는 3개의 대학 병원에서 19 명의 염증성 장질환 환자와 19 명의 건강한 피험자를 대상으로 수집되었습니다. Microbiota 분석은 세포 외 소포 (EV)를 사용하여 4가지 유형의 샘플 모두에 대해 수행되었으며, 대변 및 타액 샘플에는 NGS (Next Generation Sequencing) 분석을 같이 시행하였습니다. 환자 그룹에는 9명의 궤양성 대장염 환자와 10명의 크론병 환자가 있었고, 각 샘플의 미생물 총은 항 TNF-α 처리 전과 치료 3 개월 후에 분석되었습니다. 대변에서 항 TNF-α 처리 전과 후에 NGS 분석을 사용한 검사에서, α-diversity 에는 유의한 차이가 있었지만 타액 샘플에서는 차이가 없었습니다. 또한, EVs 분석을 이용한 4가지 샘플 분석에서 anti-TNF-α 처리 전후의 α-diversity는 차이가 없었습니다. Firmicutes (phylum), Clostridia (class) 및 Ruminococcaceae (family)는 치료 전 대변에서 유의하게 높았으며, Prevotella는 항 TNF-α 치료 후 반응이 있던 환자의 치료 전 타액에서 유의하게 높았습니다. 혈청과 소변의 추적 관찰에서 Lachnospiraceae은 anti-TNF-α 치료 후 비반응군에서 유의하게 증가하는 것으로 나타났습니다. 또한, 비반응자에서 치료 전후의 대변, 타액, 혈청 및 소변에서 Acidovorax caeni가 검출되지 않았습니다. 결론적으로, 여러 부위의 microbiome 전체 변화는 염증성 장질환 환자에서 항 TNF-α 치료의 효과를 예측할 수 있습니다. 또한 세포 외 소포를 이용한 미생물 분석은 다양한 체액에서 쉽게 검사할 수 있으므로 염증성 장질환 환자에서 더 많은 연구를 기대할 수 있습니다. Inflammatory bowel diseases (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), are chronic immune-mediated intestinal inflammatory disorders associated with microbial dysbiosis at multiple sites, particularly the gut. Anti-tumor necrosis factor-α (TNF-α) agents are important treatments for IBD. This study investigated whether microbiome changes at multiple sites can predict the effectiveness of such treatment in IBD. Stool, saliva, serum, and urine biosamples were collected from 19 IBD patients (10 with CD and 9 with UC) before (V1) and 3 months after (V2) anti-TNF-α treatment and 19 healthy subjects from three University Hospitals. Microbiota analysis was performed using extracellular vesicles (EVs) for all four sample types and next generation sequencing (NGS) for stool and saliva. Microbiome diversity before and after treatment was assessed. Using NGS analysis, there were significant differences in α-diversity at V1 and V2 in stool, but not saliva, samples. Moreover, there were no differences in α-diversity at V1 and V2 in any sample type using EV analysis. Responders to anti-TNF-α treatment had significantly higher levels of Firmicutes (phylum), Clostridia (class), and Ruminococcaceae (family) in V1 stool, and Prevotella in V1 saliva. In non-responders, serum and urine levels of Lachnospiraceae were significantly higher than in responders at V2 and, unlike responders, Acidovorax caeni was not detected in any sample type at V1 or V2. Microbiome changes at multiple sites can predict the effectiveness of anti TNF-α treatment in IBD. As microbial analysis using EVs can be easily conducted, further research in this area would be warranted in IBD.open박

The outcomes and risk factors of early readmission in patients with intestinal Behcet's disease

Hospital readmission rate is an integral quality of care measurement for hospitalized patients which is unknown for intestinal Behçet's disease cases. The purpose of this study was to investigate the risk factors and outcomes for patients readmitted early with intestinal Behçet's disease. We retrospectively reviewed patients with intestinal Behçet's disease who were readmitted to our hospital between 2005 and 2016. We then analyzed the risk factors and outcomes for early readmission within 3 months. Of the 204 patients who were readmitted, 103 patients (50.5%) were readmitted within 3 months and 101 (49.5%) were never readmitted or readmitted after 3 months. After multivariate analysis, hospital stay at the first admission (adjusted odds ratio [OR], 0.945; 95% confidence interval [CI], 0.908-0.982; P = 0.004), high disease activity index for intestinal Behçet's disease score (adjusted OR, 1.111; 95% CI, 1.060-1.165; P < 0.001), corticosteroid use (adjusted OR, 3.179; 95% CI, 1.135-8.910; P = 0.028), and opioid use (adjusted OR, 7.979; 95% CI, 1.084-58.755; P = 0.041) were independent factors for early readmission. We identified four independent prognostic factors for early readmission within 3 months, which might help guide appropriate management strategies for hospitalized patients with intestinal Behçet's disease.restrictio

Outcomes of stent insertion and mortality in obstructive stage IV colorectal cancer patients through 10 year duration

BACKGROUND: Colorectal stents are frequently used in patients with stage IV colorectal cancer with obstruction. However, there are only few studies on changes in outcomes of these patients and on the effect of stents on outcome over a long period of time with ongoing changes in therapeutic strategy, including chemotherapy. METHODS: We retrospectively evaluated 353 patients with bowel obstruction in stage IV colorectal cancer who underwent colonic stenting between years 2005 and 2014. The study population was divided into three groups based on time periods: 2005-2008, 2009-2011, and 2012-2014. RESULTS: The frequency of colorectal stent insertion procedure increased over the time periods (13.8%, 18.3%, and 20.8%, respectively). There were no changes in success rate and total complication rate. However, the early complication rate in the 3rd period was significantly lower than in the other periods (15.4% vs. 17.1% vs. 7.2%; P = 0.039). In the multivariate analysis, carcinomatosis (hazard ratio, 1.478; 95% confidence interval, 1.016-2.149; P = 0.041) and covered or partial-covered stent (hazard ratio, 1.733; 95% confidence interval, 1.144-2.624; P = 0.009; hazard ratio, 1.988; 95% confidence interval, 1.132-3.493; P = 0.017, respectively) were associated with increased complication rate. Stent-related perforation was an independent risk factor related with increased mortality. Although survival duration increased over time (P = 0.042), the mortality rate was unchanged across the three time periods. CONCLUSIONS: Over 10 years, the targeted agent use and survival duration increased, and early complication rate was decreased, without change in late complication rate or mortality rate during the three time periods in patients with obstructive stage IV colorectal cancer and stent insertion.restrictio