Microscopic colitis: A review of etiology, treatment and refractory disease

Microscopic colitis is a common cause of chronic, nonbloody diarrhea. Microscopic colitis is more common in women than men and usually affects patients in their sixth and seventh decade. This article reviews the etiology and medical management of microscopic colitis. The etiology of microscopic colitis is unknown, but it is associated with autoimmune disorders, such as celiac disease, polyarthritis, and thyroid disorders. Smoking has been identified as a risk factor of microscopic colitis. Exposure to medications, such as non-steroidal anti-inflammatory drugs, proton pump inhibitors, and selective serotonin reuptake inhibitors, is suspected to play a role in microscopic colitis, although their direct causal relationship has not been proven. Multiple medications, including corticosteroids, anti-diarrheals, cholestyramine, bismuth, 5-aminosalicylates, and immunomodulators, have been used to treat microscopic colitis with variable response rates. Budesonide is effective in inducing and maintaining clinical remission but relapse rate is as high as 82% when budesonide is discontinued. There is limited data on management of steroid-dependent microscopic colitis or refractory microscopic colitis. Immunomodulators seem to have low response rate 0%-56% for patients with refractory microscopic colitis. Response rate 66%-100% was observed for use of anti-tumor necrosis factor (TNF) therapy for refractory microscopic colitis. Anti-TNF and diverting ileostomy may be an option in severe or refractory microscopic colitis

Suspected Blood Indicator to Identify Active Gastrointestinal Bleeding: A Prospective Validation

Background: The suspected blood indicator (SBI) function in the RAPID Reader v8.3 program was designed to quickly identify the presence of blood in video capsule endoscopy. While previous retrospective studies have shown that the SBI function was accurate in detecting the presence of active bleeding in the small bowel, its specificity and sensitivity were poor. Methods: An initial retrospective review (phase 1) compared 115 patients with active gastrointestinal bleeding seen on video capsule endoscopy (VCE) to 115 patients with no active bleeding seen on VCE to produce a highly accurate algorithm. A prospective study (phase 2) was then performed by applying the algorithm to 100 consecutive patients who received VCE for the following indications: obscure bleeding, iron deficiency anemia, melena, and hematochezia. Results: The initial retrospective review found that eight contiguous SBI markers had a specificity of 100% in identifying active gastrointestinal bleeding regardless of the total number of SBI markers, while two or more contiguous SBI markers had a sensitivity of 96.5%. Using a cutoff of eight contiguous SBI markers, the prospective arm found that there was a 100% sensitivity and specificity in detecting active gastrointestinal bleeding (P \u3c 0.001). Conclusions: The SBI function can greatly facilitate the identification of active gastrointestinal bleeding on VCE by using eight contiguous SBI markers as a cutoff for active bleeding

Video Capsule Endoscopy in Patients with Muir-Torre Syndrome

Introduction: Muir-Torre Syndrome (MTS) is a rare, primarily autosomal dominant disorder that is distinguished by having sebaceous skin malignancies in addition to visceral malignancies. The most common form of MTS is a variant of HNPCC. Our aim is to demonstrate the utilization of VCE in patients with MTS as the first line screening method. Methods: Single center, retrospective chart review study of outpatients with MTS who underwent a video capsule endoscopy study between January 2006 and January 2016. Results: Four patients, all women and mean age of 57 years old, with MTS underwent a video capsule endoscopy at our institution. In 75% of the patients, VCE detected polyps at a point in the small bowel which upper endoscopy and colonoscopy did not visualize. Two patients had large jejunal polyps, approximately 20mm in diameter. One patient had multiple 3-20mm sessile polyps from the duodenum to the ileum. On endoscopy, only one of the patients had a polyp detected and it was a 10mm polyp in the stomach which was positive for GIST. With regards to colonoscopy, 2 of the patients had critical findings of colonic mucosa with focal adenomatous changes and cryptitis (high grade dysplasia) and T1 poorly differentiated signet cell carcinoma respectively. Both of these patients underwent total colectomies. Cumulatively, all four of these patients have undergone 17 endoscopies/colonoscopies. Conclusion: MTS is a disorder that needs to be monitored closely as patients have a high propensity of developing gastrointestinal malignancies. Current recommendations are colonoscopies annually starting at ages 20-25 and endoscopies with gastric antrum biopsies starting at ages 30-35. 75% of the patients had lesions in the small bowel that were only picked up by VCE. Failure to detect asymptomatic advanced lesions in the small bowel may have serious consequences. We therefore recommend pan-endoscopy in this rare syndrome

Utilizing Mucosal Protrusion Angles to Discriminate Between True and False Masses of the Small Bowel on Video Capsule Endoscopy

Background: Video capsule endoscopy (VCE) has significantly improved our ability to detect small bowel tumors. However, diagnosing small bowel tumors has remained a challenge due to their low incidence, nonspecific presentations, and the inability to use VCE to biopsy lesions identified during passage through the small bowel. To address this challenge, Girelli et al. developed a novel scoring system called the “smooth, protruding lesions index at capsule endoscopy” (SPICE) to distinguish true submucosal masses from innocent bulges1. In our study, we compared the utility of an additional morphologic criterion, the mucosal protrusion angle, with SPICE scores in detecting true submucosal masses of the small-bowel. Methods: We retrospectively reviewed the charts of 300 patients over the age of 18 who had undergone VCE for suspected small bowel lesions between the years of 2002 and 2017. In total, we analyzed the VCEs of 36 patients. SPICE scores were calculated for each patient as outlined in Girelli et al. and mucosal protrusion angles were measured using a protractor placed on the computer screen. We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of both SPICE and protrusion angle. The protrusion angle was defined as the angle between the polyp and surrounding mucosa, and we hypothesized that an angle \u3e 900 suggested an external protrusion while an angle \u3c 900 suggested a submucosal mass or true polyp. Results: 25 patients had true submucosal masses (2 GIST, 6 carcinoid, 5 Peutz-Jeghers, 3 inflammatory polyps, 2 hamartomatous polyps, 1 lymphoma, 1 lipomatous polyp, 2 tubular adenomas, 1 leiomyoma, 1 cavernous hemangioma, 1 hyperplastic polyp, 1 lymphatic nodule), and 10 patients had innocent bulges due to extrinsic compression. True submucosal masses when compared to innocent bulges had an average measured angle of protrusion of 45.70 ± 20.80 vs. 108.60 ± 16.30 (p \u3c 0.0001; unpaired t-test). When compared with SPICE scores, a mucosal protrusion angle \u3c 900 had a higher sensitivity (96.0% vs. 35.0%), specificity (90.0% vs. 82.0%), PPV (96.0% vs. 82.0%) and NPV (90.0% vs. 35.0%). Acute angle of protrusion accurately discriminated between true submucosal masses and extrinsic compression bulges on Fisher’s exact test (p = 0.0001). Conclusion: Protrusion angle is a simple and useful tool for differentiating between true submucosal masses and innocent bulges of the small-bowel. Further prospective studies are needed to validate its utility in minimizing invasive interventions

Video capsule endoscopy as a tool for evaluation of obscure overt gastrointestinal bleeding in the intensive care unit

Background and study aims: Video capsule endoscopy (VCE) is a minimally invasive tool that helps visualize the gastrointestinal tract from the esophagus to the right colon without the need for sedation or preparation. VCE is safe with very few contraindications. However, its role and safety profile in the intensive care unit (ICU) population have not been reported. The aim of this study is to evaluate the safety, efficacy, and feasibility of VCE use in ICU patients. Patients and methods: We conducted a single-center retrospective observational study of patients who underwent VCE for evaluation of obscure overt gastrointestinal bleeding in the ICU between 2008 and 2016. Results: This study included 48 patients who were admitted to the UMass Memorial Medical Center ICUs for gastrointestinal bleeding. VCE was successfully completed in 43/48 (90 %) patients. The entire length of small bowel could be evaluated in 75 % and the source of bleeding was identified in 44 % of the patients. The most commonly identified source of bleeding included small bowel angioectasias, duodenal erosions/ulcers, and small bowel polyps. No major complications could be attributed to the VCE. Only 1 capsule was retained after 2 wk; however, there was no incidence of bowel obstruction, perforation, or capsule aspiration. Conclusions: This observational retrospective study demonstrates that VCE may be a safe, feasible, and effective diagnostic tool in evaluation of gastrointestinal bleeding in the ICU population with few complications. VCE may be a safe diagnostic prelude and be a guide to the correct therapeutic procedure if needed, in the context of patients who are seriously ill

Video Capsule Endoscopy as First Procedure for Acute Gastrointestinal Bleeding: An Approach to Minimizing Exposure to SARS-CoV-2 and Conserving Resources

Introduction: Video capsule endoscopy (VCE) has been proposed as an alternative triaging tool for diagnosis of hematemesis and non-hematemesis (GIB). Randomized controlled trials have shown higher detection rates of bleeding with VCE when used as the first procedure compared with standard of care (SOC). This approach has been shown to be safe, and well tolerated. VCE is particularly suitable for the diagnosis of GIB in suspected/established SARS-CoV-2 (COVID) patients as it requires minimal patient contact (one staff person) to set up, and it avoids aerosolization and sedation. We used VCE as the first diagnostic modality in hemodynamically stable patients with GIB. Here we report the outcomes of the first 50 patients undergoing VCE in the COVID era as compared to 57 historical controls in the pre-COVID era. Methods: Hemodynamically stable patients with suspected GIB/severe anemia admitted to our hospital between March and May 2020 and who underwent VCE as the first line diagnostic modality composed the experimental group. Demographic, clinical, and outcome data was collected and analyzed. The control group comprised of patients undergoing evaluation for GIB by SOC at our hospital in January 2020. Continuous variables were compared using Student t-test. Categorical variables were compared using Fisher’s exact test. Results: Patients in both groups had similar baseline characteristics. More patients in the COVID cohort presented with melena and fewer presented with hematochezia as their manifestation of their GIB. This difference was only significant for hematochezia. Bleeding could be localized in 38 (76%) of the COVID cohort patients as compared to 36 (63%) of the historical controls using the first diagnostic modality, p \u3e 0.05 significant. Only 22 (44%) of the VCE patients underwent additional invasive diagnostic/therapeutic maneuvers and the majority were spared more invasive testing. Only 13 (26%) of the VCE patients, as compared to 47 (82%) of the historical controls underwent upper endoscopy for evaluation of GIB. There was no significant difference in transfusion requirements, degree of hemoglobin drop, in-hospital mortality, re-admission or rebleeding rates between the two groups. Conclusion: VCE appears to be a safe alternative to traditional diagnostic evaluation of GIB in the era of COVID. It reduced risk of exposure of staff to endoscopic aerosols, conserved personal protective equipment and reduced staff utilization

Does White Clover (Trifolium repens) Abundance in Temperate Pastures Determine Sitona obsoletus (Coleoptera: Curculionidae) Larval Populations?

To determine if host plant abundance determined the size of clover root weevil (CRW) Sitona obsoletus larval populations, a study was conducted over four years in plots sown in ryegrass (Lolium perenne) (cv. Nui) sown at either 6 or 30 kg/ha and white clover (Trifolium repens) sown at a uniform rate of 8 kg/ha. This provided a range of % white clover content to investigate CRW population establishment and impacts on white clover survival. Larval sampling was carried out in spring (October) when larval densities are near their spring peak at Lincoln (Canterbury, New Zealand) with % clover measured in autumn (April) and spring (September) of each year. Overall, mean larval densities measured in spring 2012, 2013, 2014 and 2015 were 310, 38, 59 and 31 larvae m-2, respectively. There was a significant decline in larval populations between 2012 and 2013, but spring populations were relatively uniform thereafter. The mean % white clover measured in autumns of 2012 to 2015 was 17, 10, 3 and 11%, respectively. In comparison, mean spring % white clover from 2012 to 2015, averaged c. 5% each year. Analysis relating spring (October) larval populations to % white clover measured in each plot in autumn (April) found the 2012 larval population to be statistically significantly larger in the ryegrass 6 kg/ha plots than 30 kg/ha plots. Thereafter, sowing rate had no significant effect on larval populations. From 2013 to 2015, spring larval populations had a negative relationship with the previous autumn % white clover with the relationship highly significant for the 2014 data. When CRW larval populations in spring 2013 to 2015 were predicted from the 2013 to 2015 autumn % white clover, respectively, based on their positive relationship in 2012, the predicted densities were substantially larger than those observed. Conversely, when 2015 spring larval data and % clover was regressed against 2012-2014 larval populations, observed densities tended to be higher than predicted, but the numbers came closer to predicted for the 2013 and 2014 populations. These differences are attributed to a CRW population decline that was not accounted by % white clover changes, the CR

Clostridium difficile in Inflammatory Bowel Disease: A Retrospective Study

Aim: To investigate the epidemiology and risk factors of Clostridium difficile infections (CDI) in patients with inflammatory bowel disease (IBD). Methods: This is a retrospective study of patients diagnosed with IBD. 1006 charts were screened and 654 patients met the inclusion criteria. Patients were divided into 2 cohorts based on the presence of prior diagnosis of CDI. Statistical analysis with Pearson\u27s chi-squared and two-sample t-test was performed. Results: The incidence of CDI among IBD patients was 6.7%. There was equal prevalence of CDI among Crohn\u27s disease (CD) (n = 21, 49%) and ulcerative colitis (UC) (n = 22, 51%). IBD patients acquired CDI at a mean age of 42.7 years, with 56% of infections acquired in the community and only 28% associated with healthcare. Only 30% of IBD patients with CDI had prior antibiotic use, and 16% had prior steroid use. IBD patients were significantly more likely to require biologic therapy (57% versus 37%, p \u3c 0.01) and have extraintestinal manifestations of IBD (43% versus 28%, p \u3c 0.02). Conclusions: IBD patients are more susceptible to CDI at a younger age and often lack traditional risk factors. IBD patients with at least one CDI were more likely to require biologic therapy and had greater rates of extraintestinal manifestations

An anti-inflammatory diet as treatment for inflammatory bowel disease: a case series report

BACKGROUND: The Anti-Inflammatory Diet (IBD-AID) is a nutritional regimen for inflammatory bowel disease (IBD) that restricts the intake of certain carbohydrates, includes the ingestion of pre- and probiotic foods, and modifies dietary fatty acids to demonstrate the potential of an adjunct dietary therapy for the treatment of IBD. METHODS: Forty patients with IBD were consecutively offered the IBD-AID to help treat their disease, and were retrospectively reviewed. Medical records of 11 of those patients underwent further review to determine changes in the Harvey Bradshaw Index (HBI) or Modified Truelove and Witts Severity Index (MTLWSI), before and after the diet. RESULTS: Of the 40 patients with IBD, 13 patients chose not to attempt the diet (33%). Twenty-four patients had either a good or very good response after reaching compliance (60%), and 3 patients\u27 results were mixed (7%). Of those 11 adult patients who underwent further medical record review, 8 with CD, and 3 with UC, the age range was 19-70 years, and they followed the diet for 4 or more weeks. After following the IBD-AID, all (100%) patients were able to discontinue at least one of their prior IBD medications, and all patients had symptom reduction including bowel frequency. The mean baseline HBI was 11 (range 1-20), and the mean follow-up score was 1.5 (range 0-3). The mean baseline MTLWSI was 7 (range 6-8), and the mean follow-up score was 0. The average decrease in the HBI was 9.5 and the average decrease in the MTLWSI was 7. CONCLUSION: This case series indicates potential for the IBD-AID as an adjunct dietary therapy for the treatment of IBD. A randomized clinical trial is warranted

Carcinoids and Capsules: A Case Series Highlighting the Utility of Capsule Endoscopy in Patients With Small Bowel Carcinoids

Background: Neuroendocine tumors (NETs) or carcinoids arise at many different sites of the gastrointestinal tract. The small intestine is the most common site for NETs. Diagnosing small bowel carcinoids remains challenging given their non-specific presentations and the overall low incidence of small bowel tumors. Video capsule endoscopy (VCE) has significanly improved our ability to detect small bowel malignancies. We explore the value of VCE in the initial workup and management of a series of small bowel carcinoid patients. Methods: We retrospectively analyzed adult patients undergoing surgical management for small bowel lesions from July 2005 to September 2015 at a tertiary care center. Patient characteristics, presenting symptomatology, diagnostic workup and surgical management were analyzed among patients with histologically confirmed small bowel carcinoid tumors. Results: Our study identified 16 patients treated surgically for small bowel carcinoids. The majority of patients (87.5%) presented with either occult gastrointestinal bleeding or anemia. Most patients (87.5%) were initially evaluated with various endoscopic and imaging modalities before all ultimately undergoing surgery. Seventy-five percent of patients had a VCE, with 83.3% (10/12) having positive findings that correlated with intraoperative findings compared to 62.5% (5/8) with computed tomography scan, 21.4% (3/14) with colonoscopy, 44% (4/9) with deep enteroscopy, and 0% (0/9) with esophagogastroduodenoscopy (EGD). Conclusions: In the absence of any contraindications, VCE is an effective endoscopic modality in the diagnostic workup of small bowel NETs. Furthermore, positive VCE findings appear to highly correlate with surgical findings, thus suggesting a valuable role for VCE in the initial surgical assessment of patients with small bowel NETs