Updates in the diagnosis and management of small-bowel Crohn's disease

Crohn's disease (CD) can affect any part of the GI tract, but small bowel (SB) involvement is present in 80% of patients with CD; 30% have exclusive SB disease [1] presenting a diagnostic challenge due to the inaccessibility of standard endoscopic techniques. Accurate assessment of treatment response [2] and regular monitoring are crucial to prevent surgery and to identify patients at risk of relapse and/or complications before the onset of clinical symptoms [3]. Ileocolonoscopy (IC) is considered the gold standard for evaluating mucosal healing (MH) in CD, but it is invasive and costly [4] and only allows visualization of the terminal ileum (TI). The CALM study has demonstrated that C-reactive protein (CRP) and faecal calprotectin (FCP) can be effective surrogate markers of MH and help guide treatment [5]. Nonetheless, their efficacy is limited [6] as approximately 30% of patients do not present with elevated CRP levels during relapse [7] and the correlation between FCP and active SB disease is weak [8]. Thus, CD requires a multidisciplinary approach. We aim to provide an overview of recent advances in the diagnosis and management of small bowel CD

Panenteric capsule endoscopy identifies proximal small bowel disease guiding upstaging and treatment intensification in Crohn’s disease: A European multicentre observational cohort study

Background: Endoscopically defined mucosal healing in Crohn\u2019s disease is associated with improved outcomes. Panenteric capsule endoscopy enables a single non-invasive assessment of small and large bowel mucosal inflammation. Aims and methods: This multicentre observational study of patients with suspected and established Crohn\u2019s disease examined the feasibility, safety and impact on patient outcomes of panenteric capsule endoscopy in routine clinical practice. The potential role in assessment of disease severity and extent by a comparison with existing clinical and biochemical markers is examined. Results: Panenteric capsule endoscopy was performed on 93 patients (71 with established and 22 with suspected Crohn\u2019s disease). A complete examination occurred in 85% (79/93). Two cases (2.8%) of capsule retention occurred in patients with established Crohn\u2019s disease. Panenteric capsule resulted in management change in 38.7% (36/93) patients, including 64.6% (32/48) of those with an established diagnosis whose disease was active, and all three patients with newly diagnosed Crohn\u2019s disease. Montreal classification was upstaged in 33.8% of patients with established Crohn\u2019s disease and mucosal healing was demonstrated in 15.5%. Proximal small bowel disease upstaged disease in 12.7% and predicted escalation of therapy (odds ratio 40.3, 95% confidence interval 3.6\u2013450.2). Raised C-reactive protein and faecal calprotectin were poorly sensitive in detecting active disease (0.48 and 0.59 respectively). Conclusions: Panenteric capsule endoscopy was feasible in routine practice and the ability to detect proximal small bowel disease may allow better estimation of prognosis and guide treatment intensification. Panenteric capsule endoscopy may be a suitable non-invasive endoscopic investigation in determining disease activity and supporting management decisions

Nomenclature and semantic description of vascular lesions in small bowel capsule endoscopy: an international Delphi consensus statement

Background and study aims \u2002Nomenclature and descriptions of small bowel (SB) vascular lesions in capsule endoscopy (CE) are scarce in the medical literature. They are mostly based on the reader's opinion and thus differ between experts, with a potential negative impact on clinical care, teaching and research regarding SBCE. Our aim was to better define a nomenclature and to give a description of the most frequent vascular lesions in SBCE. Methods \u2002A panel of 18 European expert SBCE readers was formed during the UEGW 2016 meeting. Three experts constructed an Internet-based four-round Delphi consensus, but did not participate in the voting process. They built questionnaires that included various still frames of vascular lesions obtained with a third-generation SBCE system. The 15 remaining participants were asked to rate different proposals and description of the most common SB vascular lesions. A 6-point rating scale (varying from 'strongly disagree' to 'strongly agree') was used successive rounds. The consensus was reached when at least 80\u200a% voting members scored the statement within the 'agree' or 'strongly agree'. Results \u2002Consensual terms and descriptions were reached for angiectasia/angiodysplasia, erythematous patch, red spot/dot, and phlebectasia. A consensual description was reached for more subtle vascular lesions tentatively named "diminutive angiectasia" but no consensus was reached for this term. Conclusion \u2002An international group has reached a consensus on the nomenclature and descriptions of the most frequent and relevant SB vascular lesions in CE. These terms and descriptions are useful in daily practice, for teaching and for medical research purposes

Hyperemesis gravidarum and subsequent breast cancer risk

Both parity and a young age at first pregnancy are associated with a reduction in breast cancer risk. The hormones involved in this process are not fully investigated. Human chorionic gonadotropin is a placental hormone, which in rats and in human breast cells in vitro has been shown to prevent against breast cancer. Hyperemesis, a severe nausea combined with vomiting during pregnancy, is associated with increased levels of human chorionic gonadotropin. We investigated the possible relationship between hyperemesis and subsequent breast cancer risk in a case–control study based on registry data. Among 13 079 breast cancer cases and 34 348 individually matched controls we found 148 cases and 405 controls who had been hospitalised for hyperemesis. Hyperemesis was not associated with breast cancer risk (adjusted odds ratio 1.05, 95% confidence interval 0.86–1.27), and similar risks were observed regardless of age at diagnosis, number of hospitalisations for hyperemesis or time of follow-up. Our results do not support the hypothesis that human chorionic gonadotropin is responsible for the protective effect of pregnancies upon breast cancer risk

Population pharmacokinetics of colistin and the relation to survival in critically ill patients infected with colistin susceptible and carbapenem-resistant bacteria

Objectives: The aim was to analyse the population pharmacokinetics of colistin and to explore the relationship between colistin exposure and time to death. Methods: Patients included in the AIDA randomized controlled trial were treated with colistin for severe infections caused by carbapenem-resistant Gram-negative bacteria. All subjects received a 9 million units (MU) loading dose, followed by a 4.5 MU twice daily maintenance dose, with dose reduction if creatinine clearance (CrCL) 2 mg/L in 94% (195/208) and 44% (38/87) of patients with CrCL ≤120 mL/min, and >120 mL/min, respectively. Colistin methanesulfonate sodium (CMS) and colistin clearances were strongly dependent on CrCL. High colistin exposure to MIC ratio was associated with increased hazard of death in the multivariate analysis (adjusted hazard ratio (95% CI): 1.07 (1.03–1.12)). Other significant predictors included SOFA score at baseline (HR 1.24 (1.19–1.30) per score increase), age and Acinetobacter or Pseudomonas as index pathogen. Discussion: The population pharmacokinetic model predicted that >90% of the patients had colistin concentrations

Small bowel enteroclysis with magnetic resonance imaging and computed tomography in patients with failed and uncertain passage of a patency capsule

<p>Abstract</p> <p>Background</p> <p>Video capsule enteroscopy (VCE) has revolutionized small bowel imaging, enabling visual examination of the mucosa of the entire small bowel, while MR enteroclysis (MRE) and CT enteroclysis (CTE) have largely replaced conventional barium enteroclysis. A new indication for MRE and CTE is the clinical suspicion of small bowel strictures, as indicated by delayed or non-delivery of a test capsule given before a VCE examination, to exclude stenosis. The aim of this study was to determine the clinical value of subsequent MRE and CTE in patients in whom a test capsule did not present itself in due time.</p> <p>Methods</p> <p>Seventy-five consecutive patients were identified with a delayed or unnoticed delivery of the test capsule. Seventy patients consented to participate and underwent MRE (44) or CTE (26). The medical records and imaging studies were retrospectively reviewed and symptoms, laboratory results and imaging findings recorded.</p> <p>Results</p> <p>Lesions compatible with Crohns disease were shown by MRE in 5 patients, by CTE in one and by VCE in four, one of whom had lesions on MRE. In patients without alarm symptoms and findings (weight loss, haematochezia, anaemia, nocturnal diarrheoa, ileus, fistula, abscess and abnormal blood tests) imaging studies did not unveil any such lesion. VCE's were performed in only 20 patients, mainly younger than 50 years of age, although no stenotic lesion was shown by MRE and CTE. In the remaining 50 patients no VCE or other endoscopic intervention was performed indicating that the referring physician was content with the diagnostic information from MRE or CTE.</p> <p>Conclusion</p> <p>The diagnostic value of MRE and CTE is sufficient for clinical management of most patients with suspected small bowel disease, and thus VCE may be omitted or at least postponed for later usage.</p

Imaging alternatives to colonoscopy: CT colonography and colon capsule. European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guideline – Update 2020

1. ESGE/ESGAR recommend computed tomographic colonography (CTC) as the radiological examination of choice for the diagnosis of colorectal neoplasia. Strong recommendation, high quality evidence. ESGE/ESGAR do not recommend barium enema in this setting. Strong recommendation, high quality evidence. 2. ESGE/ESGAR recommend CTC, preferably the same or next day, if colonoscopy is incomplete. The timing depends on an interdisciplinary decision including endoscopic and radiological factors. Strong recommendation, low quality evidence. ESGE/ESGAR suggests that, in centers with expertise in and availability of colon capsule endoscopy (CCE), CCE preferably the same or the next day may be considered if colonoscopy is incomplete. Weak recommendation, low quality evidence. 3. When colonoscopy is contraindicated or not possible, ESGE/ESGAR recommend CTC as an acceptable and equally sensitive alternative for patients with alarm symptoms. Strong recommendation, high quality evidence. Because of lack of direct evidence, ESGE/ESGAR do not recommend CCE in this situation. Very low quality evidence. ESGE/ESGAR recommend CTC as an acceptable alternative to colonoscopy for patients with non-alarm symptoms. Strong recommendation, high quality evidence. In centers with availability, ESGE/ESGAR suggests that CCE may be considered in patients with non-alarm symptoms. Weak recommendation, low quality evidence. 4. Where there is no organized fecal immunochemical test (FIT)-based population colorectal screening program, ESGE/ESGAR recommend CTC as an option for colorectal cancer screening, providing the screenee is adequately informed about test characteristics, benefits, and risks, and depending on local service- and patient-related factors. Strong recommendation, high quality evidence. ESGE/ESGAR do not suggest CCE as a first-line screening test for colorectal cancer. Weak recommendation, low quality evidence. 5. ESGE/ESGAR recommend CTC in the case of a positive fecal occult blood test (FOBT) or FIT with incomplete or unfeasible colonoscopy, within organized population screening programs. Strong recommendation, moderate quality evidence. ESGE/ESGAR also suggest the use of CCE in this setting based on availability. Weak recommendation, moderate quality evidence. 6. ESGE/ESGAR suggest CTC with intravenous contrast medium injection for surveillance after curative-intent resection of colorectal cancer only in patients in whom colonoscopy is contraindicated or unfeasible. Weak recommendation, low quality evidence. There is insufficient evidence to recommend CCE in this setting. Very low quality evidence. 7. ESGE/ESGAR suggest CTC in patients with high risk polyps undergoing surveillance after polypectomy only when colonoscopy is unfeasible. Weak recommendation, low quality evidence. There is insufficient evidence to recommend CCE in post-polypectomy surveillance. Very low quality evidence. 8. ESGE/ESGAR recommend against CTC in patients with acute colonic inflammation and in those who have recently undergone colorectal surgery, pending a multidisciplinary evaluation. Strong recommendation, low quality evidence. 9. ESGE/ESGAR recommend referral for endoscopic polypectomy in patients with at least one polyp ≥6 mm detected at CTC or CCE. Follow-up CTC may be clinically considered for 6–9-mm CTC-detected lesions if patients do not undergo polypectomy because of patient choice, comorbidity, and/or low risk profile for advanced neoplasia. Strong recommendation, moderate quality evidence.Source and scop